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Female subfertility

Abstract

Subfertility is common and affects one in six couples, half of whom lack an explanation for their delay in conceiving. Developments in the diagnosis and treatment of subfertility over the past 50 years have been truly remarkable. Indeed, current generations of couples with subfertility are more fortunate than previous generations, as they have many more opportunities to become parents. The timely access to effective treatment for subfertility is important as many couples have a narrow window of opportunity before the age-related effects of subfertility limit the likelihood of success. Assisted reproduction can overcome the barriers to fertility caused by tubal disease and low sperm count, but little progress has been made in reducing the effect of increasing age on ovarian function. The next 5–10 years will likely see further increases in birth rates in women with subfertility, a greater awareness of lifestyle factors and a possible refinement of current assisted reproduction techniques and the development of new ones. Such progress will bring challenging questions regarding the potential benefits and harms of treatments involving germ cell manipulation, artificial gametes, genetic screening of embryos and gene editing of embryos. We hope to see a major increase in fertility awareness, access to safe and cost-effective fertility care in low-income countries and a reduction in the current disparity of access to fertility care.

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Fig. 1: The female genital tract and factors that affect fertility.
Fig. 2: The prevalence of primary infertility in 2010.
Fig. 3: Reduction in natural fertility with increasing age.
Fig. 4: The ovarian and menstrual cycle.
Fig. 5: Investigations for subfertility.
Fig. 6: Assessment of tubal patency.
Fig. 7: IVF procedure.

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Acknowledgements

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Nature Reviews Disease Primers thanks N. Gleicher, R. Hart, R. Homburg, R. Norman and other anonymous reviewer(s) for their contribution to the peer review of this work.

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Contributions

Introduction (C.M.F.); Epidemiology (S.B. and M.S.K.); Mechanisms/pathophysiology (S.R. and S.M.); Diagnosis, screening and prevention (S.B. and M.S.K.); Management (C.M.F. and J.M.); Quality of life (J.B.); Outlook (C.M.F., S.R., J.B., J.M. and S.M.); overview of the Primer (C.M.F.).

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Correspondence to Cynthia M. Farquhar.

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Competing interests

J.B. has received funding from Merck Norway (Merck AB NUF) for the Norwegian translation of the Fertility Quality of Life (FertiQoL) tool and funding from Ferring International Center SA for the Czech translation of the FertiQoL scale. J.B. has also collaborated on an exploratory trial evaluating the benefits of a coping intervention on treatment discontinuation that was funded by Merck/Schering-Plough Pharmaceuticals. J.B. and her employer (Cardiff University) could one day receive royalties from the commercial use of FertiQoL. J.B. has received speaker and consultancy fees to present on the psychological impact of infertility from Actavis Generics, and IBSA Institut Biochimique, Merck/Schering-Plough Pharmaceuticals, Merck KGaA. All other authors declare no competing interests.

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Farquhar, C.M., Bhattacharya, S., Repping, S. et al. Female subfertility. Nat Rev Dis Primers 5, 7 (2019). https://doi.org/10.1038/s41572-018-0058-8

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