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INFERTILITY

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

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INFERTILITY

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  1. INFERTILITY • Assessment and treatment of patients with fertility problems Dr Nitu Raje-Ghatge

  2. 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

  3. Why learn about it.. Expectations from secondary care services! Inappropriate timing of referrals (early/late) Incomplete /inadequate investigations

  4. 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.

  5. 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.

  6. PRIMARY/SECONDARY INFERTILITY • PRIMARY – Couple without a prior pregnancy • SECONDARY – Couple with previous pregnancy including miscarriage/ectopic.

  7. Etiology: • Male factors • Female factors • Unexplained -20% • Mixed – 15%

  8. Male Account for 25% • Hypogonadotrophic hypogonadism • Obstructive azoospermia Surgery • Erectile dysfunction • Anatomical - Hypospadias - Undescended/ maldescended testis

  9. Female • Peritoneal factors 40%, - Endometriosis. • Tubal blockage 20%.

  10. 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.

  11. Fertility may be impaired in poorly controlled diabetes.

  12. History taking (female) • Symptoms (past or present) - P I D / STD, - dysparenuria - galactorrhoea, - thyroid symptoms • Obstetric history

  13. History taking (female) • Menstrual history - irregularities • Surgical history – D & C, abdominal/pelvic surgery • Contraception - IUCDs • Cervical smear

  14. 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

  15. 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

  16. IN BOTH • Smoking • Alcohol intake • Psychological factors

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

  18. Female: • Hirsuitism, galactorrhoea • Bimanual examination - adnexal masses (tubo/ovarian, ovarian cyst) - tenderness (PID/ endometriosis) - Uterine fibroids

  19. Male • Hypospadias • Size and consistency of each testicle and epididymis; • Presence of varicocele or hernia; • Size of prostate. • Gynaecomastia

  20. Now what?? Investigate Or Refer

  21. 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 Early referral if..

  22. Primary care Female Assess ovulation. Other hormonal tests Tests for PID Male Sperm analysis Secondary care Tubal patency Uterine abnormality Investigations

  23. Assessing ovulation Do if • regular cycles with > 1 year of infertility • irregular cycles 1) Serum progesterone 2) LH/FSH levels

  24. 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

  25. Interpretation of test

  26. Assessing ovulation 2) LH/FSH levels High levels – poor ovarian function High LH compared to FSH -PCOS

  27. Other hormonal tests • E2, Testosterone levels – PCOS • Prolactin ONLY if - ovulation problems - galactorrhoea, - pituitary problem.

  28. Other hormonal tests • Thyroid tests - only with symptoms/ signs • Other androgen profile (DHEAS, Androstenedione, SBHG) – as per etiology

  29. Tests for PID • HVS • Chlamydia screening

  30. Don’t forget!! • Rubella status - check immunity - Vaccinate if non immune, avoid conception for 3 months

  31. Cervical hostility • Post coital test - no longer recommended by NICE • Mucus invasion test - doubtful significance

  32. 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

  33. 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

  34. Investigations in secondary care

  35. 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

  36. 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

  37. Positive approach Reassure about cumulative pregnancy rates

  38. 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

  39. Management in primary care • Pre conceptual advice - Folic acid supplementation - Rubella status - Cervical screening • Management of erectile dysfunction - psychosexual couselling - drugs

  40. Management in secondary care • Depends upon the etiology..

  41. Hypogonadotrophic hypogonadism • Pulsatile GnRH • Gonadotrophins with LH activity • Bromocriptine ( for hyperprolactinaemia)

  42. 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

  43. 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

  44. Others… 3) Gonadotrophins 4) Luteal phase support – - progesterone, - clomiphene 5) Laparoscopic ovarian drilling

  45. Peritoneal problems (endometriosis) • Laparoscopic surgical ablation/ resection of endometriosis + adhesiolysis • If ovarian endometriomas, laparoscopic cystectomy

  46. Uterine/ tubal factors • Tubal factors: - Laparoscopic tubal surgery/ tubal microsurgery - Salpingography + tubal catheteristion - Hysteroscopic tubal cannulation • Uterine factors - hysteroscopic adhesiolysis - myomectomy

  47. Assisted reproduction techniques • Intra uterine insemination (IUI)

  48. In vitrio fertilisation • Intracytoplasmic sperm injection (ICSI) • Donor insemination • Oocyte donation

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