Management of infertility in general practice

1. Management of infertility in general practice Rohan subasinghe

2. Some facts • Affects 1 in 6 • Fertility declines with age • 84 % - cumulative prob of pregnancy in 1st yr • 92 % - cumulative prob of pregnancy in 2nd yr • Infertility is failure to conceive after regular unprotected intercourse for 2 yrs in absence of known reproductive pathology

3. Initial management • Early investigation in – people with predisposing factors • Both partners – couple based • Rubella status • Folic acid while trying to concieve (0.4-5 mg) • Explain each stage of investigation • Detalied rug hx, drug abuse, alcohol etc

4. General advice • Give up smoking • Alcohol - 2 units for women 2-4 units for men • BMI in women– 19-29 • Men with poor quality sperm – loose underwear • Regular intercourse throughout cycle • No evidence for temperature charts

5. Initial investigations • Semen analysis – check twice • Serum progesterone in mid-luteal stage • Serum gonadotrophins • No value in thyroid/prolactin in absence of pathology and in th presence of a regular cycle

6. Semen analysis • Abstain for 3 days Vol – 2-5ml Liquefaction tuime – within 30 mins Concentration - >20 mill/ml Motility - >50 % Morphology - >30 % Wbc - <1 mill/ml

7. Mid-luteal progesterone • 7 days before period in 28 day cycle • Timing crucial • Adjust for longer periods • <16 nmol/l –repeat – refer if consistently low • >16 but <30 – repeat - if same or lower – refer • >30 – proof of ovulation

8. Flow chart - RCOG • http://www.gp-training.net/protocol/gynaecology/infert2.htm

9. Fertility algorithm - NICE • http://www.rcog.org.uk/resources/public/pdf/fertility_algorithm.pdf