Infertility - Gynaecology

Infertility

·        = Inability to establish a pregnancy within a year of unprotected intercourse or > 2 consecutive miscarriages or still births

·        Normal fecundability = 25% per month, 85% per year, 90-95% per 2 years

·        Incidence – approx 10% of couples

·        Aetiology:

o   Male factors: 30%

o   Idiopathic/unexplained: 20%

o   Ovulatory: 10%

o   Tubal: 10%

·        History:

o   Male: Previous surgery (eg hernia), undescended testes, mumps, etc 

o   Female: surgery, menstrual history, BMI, symptoms of endocrine disorders, nasty polyps, PID, ectopic pregnancy, nasty appendicitis

o   Both: general medical and reproductive history, smoking, medications, family history 

·        Exam: include general assessment of endocrine disorders: PRL (®Galactorrhoea), thyroid disorders (goitre, etc), Polycystic ovary (® hirsutism, obese, etc) 

·        Investigations: 

o   Male: semen analysis, sperm antibodies, Plasma FSH (primary or secondary testicular failure), androgen deficiency, testicular biopsy

o   Female: 

§  Possible causes: Endometriosis, stress/anorexia/exercise, early menopause, PCO, thyroid, ­PRL 

§  Ovulation: if regular menstruation then ovulation likely. Only proof is laproscopic visualisation – impractical. Can measure temperature, progesterone levels, etc 

§  Test HCG, TSH, PRL, Oestrogen (day 2), progesterone (day 21) for 3 cycles to check for consistent ovulation

§  Post-coital test of cervical mucus

§  Pelvic assessment: US, contrast x rays, etc

·        Management: 

o  Induce ovulation: risk of multiple pregnancy, also narrow TI. Anovulatory cycles: treat with Clomifene – stimulates ovulation but risk of multiple pregnancy

o  IVF (also better for tubal blockage than surgical repair).  1 in 3 have life birth.

o  Oligospermia: intracytoplasmic sperm injection, donor sperm, artificial insemination

·        Lots of psychosocial implications of infertility

·        Workup to point of diagnosis is funded.  Criteria based funding for treatment

·        Also prepare for pregnancy: take folate, do booking bloods, check rubella status and offer vaccination