INFERTILITY

Assessment and treatment of patients with fertility problems

Dr Nitu Raje-Ghatge

Why learn about it?

Its in the curriculum ! Infertility – primary/ secondary Investigations eg hormone tests Knowledge of subfertility secondary care investigations Primary care management Knowledge of specialist treatments and surgical procedures

Why learn about it..

Expectations from secondary care services! Inappropriate timing of referrals (early/late) Incomplete /inadequate investigations

What is infertility?

NICE: Failure to conceive after regular UPSI for 2 years in the

absence of reproductive pathology. P.S NICE suggests offer clinical investigations if failure to

conceive after 1 year of UPSI.

GP NOTEBOOK: Infertility is the failure of conception in a couple having regular,

unprotected coitus for 1 year, provided that normal intercourse is occurring not less than twice weekly.

Natural conception rates:

80% of couples will be pregnant after 12 cycles. 50% of remaining will conceive during a 2nd year ( hence cumulative rate 90%) 50% in the following 4 years.

PRIMARY/SECONDARY INFERTILITY

PRIMARY – Couple without a prior pregnancy

SECONDARY – Couple with previous pregnancy including miscarriage/ectopic.

Etiology:

Male factors Female factors Unexplained -20% Mixed – 15%

Male

Account for 25% Hypogonadotrophic

hypogonadism Obstructive azoospermia Surgery Erectile dysfunction Anatomical - Hypospadias - Undescended/ maldescended testis

Female

Peritoneal factors 40%,

- Endometriosis.

Tubal blockage 20%.

Etiology (female)

Ovulatory dysfunction 15-20% - Hypothalamic/hypogonadotrophic hypogonadism - Hypothalamic pituitary dysfunction (PCOS) - Ovarian failure

Uterine cavity abnormalities - Asherman's syndrome - Uterine fibroids.

Cervical hostility 5-10%, - Infection - Female sperm antibodies.

Fertility may be impaired in poorly controlled diabetes.

History taking (female)

Symptoms (past or present) - P I D / STD, - dysparenuria - galactorrhoea, - thyroid symptoms

Obstetric history

History taking (female)

Menstrual history - irregularities

Surgical history – D & C, abdominal/pelvic surgery

Contraception - IUCDs Cervical smear

History taking (male)

Symptoms h/o genital tract infection e.g. mumps orchitis, prostatitis

Surgical history - Hernia repair - Testicular surgery for torsion/ undescended /maldescended testis - Prostate surgery

History taking (male)

Trauma to the male genital or inguinal region

Occupational history - exposure to lead, cadmium

Drug history - Sulphasalazine – impairs spermatogenesis - Phenothiazines/ typical antipsychotics/ metoclopramide increase prolactin levels - Immunosuppresants

IN BOTH

Smoking Alcohol intake Psychological factors

EXAMINATION

General health and nutritional status BMI <19 (F) > 29.(M/F) SSC

Female:

Hirsuitism, galactorrhoea Bimanual examination - adnexal masses (tubo/ovarian, ovarian cyst) - tenderness (PID/ endometriosis) - Uterine fibroids

Male

Hypospadias Size and consistency of each testicle and

epididymis; Presence of varicocele or hernia; Size of prostate. Gynaecomastia

Now what??

Investigate

Or

Refer

Early referral if..

Female Age >35 years Amenorrhoea/ oligo

menorrhoea PID Abnormal pelvic exam

Male Undescended testes Previous genital pathology Previous urogenital surgery

In Both Prior treatment for cancer HIV, Hep B, Hep C

Investigations

Primary care

FemaleAssess ovulation.Other hormonal testsTests for PID

MaleSperm analysis

Secondary care

Tubal patency Uterine abnormality

Assessing ovulation

Do if regular cycles with > 1 year of infertility irregular cycles

1) Serum progesterone2) LH/FSH levels

INVESTIGATIONS (Female)

1) Serum progesterone (mid luteal phase ie day 21 of 28 week cycle) Timing is important!!!

Regular cycles - 7 days before next MP Irregular cycles - day 28/35 wk then weekly till menstruation occurs

Interpretation of test

Interpret after next LMP known

<16 nmol/l

Repeat in another cycle.Refer if consistently low

>16 nmol/l but <30 nmol/l

Repeat in another cycle.Refer if same/lower

>30 nmol/l

Consider as proof of adequate ovulation

Assessing ovulation

2) LH/FSH levels High levels – poor ovarian function High LH compared to FSH -PCOS

Other hormonal tests

E2, Testosterone levels – PCOS

Prolactin ONLY if - ovulation problems - galactorrhoea, - pituitary problem.

Other hormonal tests

Thyroid tests - only with symptoms/ signs Other androgen profile (DHEAS, Androstenedione, SBHG)

– as per etiology

Tests for PID

HVS Chlamydia screening

Don’t forget!!

Rubella status - check immunity - Vaccinate if non immune, avoid conception

for 3 months

Cervical hostility

Post coital test - no longer recommended by NICE Mucus invasion test - doubtful significance

Investigations (Male)

Semen analysis Needs prior appointment

with lab Abstinence for atleast 3 days Transport to lab in 30- 60

min Repeat abnormal test in next

3 months, earlier if gross abnormality

Semen analysis- interpretation (WHO values)

Volume 2 mls or more Sperm concentration - 20 million/ml Sperm morphology - atleast 30% normal Sperm number - 40 million/ ejaculate Sperm motility – 50% Vitality – 75% WBC - <1 million/ml

Anti sperm antibody tests- not recommended by NICE

Investigations in secondary care

Tests for uterine/tubal problems

HSG/hystero salpingo-contrast USG Laparoscopy + dye test

Done only when ovulation tests/Sperm tests normal. Choice of tests depends upon co morbidities

Management in primary care

Principles of care Couple centred management Access to evidence based information Counselling (third person) Contact with fertility support groups Specialist teams

Positive approach

Reassure about cumulative pregnancy rates

Management in primary care

Lifestyle changes - Weight reduction, BMI 19-29 - Smoking cessation- offer support groups - Alcohol reduction <1-2 units/week for women <3-4 units/week for men - S I every 2-3 days - Information about OTC/ recreational drugs

Management in primary care

Pre conceptual advice - Folic acid supplementation - Rubella status - Cervical screening

Management of erectile dysfunction - psychosexual couselling - drugs

Management in secondary care

Depends upon the etiology..

Hypogonadotrophic hypogonadism

Pulsatile GnRH Gonadotrophins with LH activity Bromocriptine ( for hyperprolactinaemia)

Ovarian dysfunction ( hypothalamic dysfunction)

1) Anti- oestrogens eg Clomiphene/ Tamoxifen

- 1st line - use for atleast 12 months if ovulating - initiated in secondary care - under USG guidance ( to adjust dose) - shared care when dose established - S/E risk of multiple pregnancy, OHSS

Ovulatory dysfunction- treatment

2) Metformin

- not licensed for ovulatory disorders in UK - used 2nd line with Clomiphene in - anovulatory women with PCOD + BMI >25 + no response to CC

Others…

3) Gonadotrophins4) Luteal phase support – - progesterone, - clomiphene

5) Laparoscopic ovarian drilling

Peritoneal problems (endometriosis)

Laparoscopic surgical ablation/ resection of endometriosis + adhesiolysis

If ovarian endometriomas, laparoscopic cystectomy

Uterine/ tubal factors

Tubal factors: - Laparoscopic tubal surgery/ tubal microsurgery - Salpingography + tubal catheteristion - Hysteroscopic tubal cannulation

Uterine factors - hysteroscopic adhesiolysis - myomectomy

Assisted reproduction techniques

Intra uterine insemination (IUI)

In vitrio fertilisation

Intracytoplasmic sperm injection (ICSI) Donor insemination Oocyte donation

ACON at CRH

Satellite IVF unit Counselling, monitoring and most of

treatment , except egg retrieval and embryo transfer.

Central unit

Clarendon Wing, LGI SJUH, Leeds CARE, Manchester

Questions…..zzzz??