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Infertility

Infertility. Definitions. Failure to conceive within 2 years of regular unprotected intercourse. Primary or secondary. 84% of couples will conceive within 1 year and 92% within 2 years. Management. History Couple should be seen together and reassured.

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Infertility

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  1. Infertility

  2. Definitions • Failure to conceive within 2 years of regular unprotected intercourse. • Primary or secondary. • 84% of couples will conceive within 1 year and 92% within 2 years.

  3. Management History • Couple should be seen together and reassured. • Woman’s age and duration of infertility. • Any history suggestive of a cause. • Investigate after one year of failure to conceive. • Investigate sooner if > 35 or history suggestive of problems.

  4. Examination Female BMI Hyperandrogenism Galactorrhea Pelvic abnormalities Male Assess genitalia if history suggestive or semenalysis abnormal

  5. Reassure women with regular cycles. • Advice re timing and frequency of intercourse. • Avoid alcohol, smoking, drugs. • Folic acid. • Weight.

  6. Baseline investigations Female • Follicular phase LH, FSH, oestradiol • Luteal phase progesterone • Rubella • Consider tubal patency test (chlamydia test first) Male • Semenalysis & repeat at 3 months if abnormal

  7. Volume >2ml • pH 7-8 • Concentration >20 x 106/ml • Motility >50% forward & >25% with rapid linear progress • Morphology > 15% normal • Alive > 50% • Antisperm antibodies Negative • WCC < 1x106

  8. Treatment Male Factor • Hypogonadotrphic hypogonadism – gonadotrophins • Obstructive azoospermia – surgical correction • Correction of varicocele

  9. Anovulation • Clomiphene days 2-6 for up to 1 year. Monitor with ultrasound for 1st cycle. • Gonadotrophins – FSH for 10 days followed by hCG. • Ovarian drilling • Metformin(evidence lacking)

  10. Tubal Disease • Ablate endometriosis at the time of laparoscopy • Tubal surgery • IVF

  11. Intrauterine Insemination • Used in unexplained or mild male factor infertility. • Outcome may be no better than expectant management.

  12. IVF • Pituitary suppression – GnRH agonist • Superovulation – FSH (hyperstimulation) • hCG to mimic LH surge • Oocyte collection • Fertilisation & incubation (ICSI) • Embryo transfer 48-72 hours later • Luteal support with progesterone

  13. Take-home baby rate 20% per cycle. • Consider alternatives: oocyte/sperm donation surrogacy adoption

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