When should investigation and referral be done for infertility?
- should be initiated after the couple has been trying to conceive without success for 12 months
- this can be reduced to 6 months if the woman is older than 35, as ovarian stores are likely to be reduced and time is precious
What are the causes of infertility?
- Sperm problems (30%)
- Ovulation problems (25%)
- Tubal problems (15%)
- Uterine problems (10%)
- Unexplained (20%)
40% of infertile couples have a mix of male and female causes
What are some general advice for couples trying to get pregnant?
- woman should be taking 400mcg folic acid daily
- aim for a healthy BMI
- avoid smoking and drinking ecessive alcohol
- reduce stress as may negatively affect libido and relationship
- aim for intercourse every 2-3 days
- avoid timing intercourse
timed intercourse to coincide with ovulation is not reccomended as it just increases stress and pressure in relationship
What are the initial investigations for infertility?
- BMI (low could indicate anovulation, high could indicate PCOS)
- chlamydia screening
- semen analysis
- female hormonal testing
- rubella immunity in the mother
What does female hormone testing involve?
- serum LH and FSH on day 2-5 of cycle
- serum progesterone on day 21 of cycle ( or 7 days before end of cycle)
- anti-mullerian hormone
- TFTs
- prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea
What would high FSH suggest?
-poor ovarian reserve (number of follicles that women has left in ovaries)
What would high LH suggest?
-polycystic ovarian syndrome
What would high progesterone on day 21 suggest?
-ovulation has occured and the corpus luteum has formed and started secreting progesterone
Why is Anti-mullerian hormone measured?
- can be measured at any time in the cycle and is the most accurate marker of ovarian reserve
- it is released by granulosa cells in the follicles and falls as the eggs are depleted.
- high level indicates a good ovarian reserve
What are the further investigation for infertility, often performed in secondary care?
- pelvic US –> to look for polycystic ovaries or any structural abnormalities in the uterus
- hysterosalpinogram –> to look at the patency of the fallopian tubes.
- laparoscopy and dye test –> to look at the patency of the fallopian tubes, adhesions, and endometriosis
What is a hysterosalpingogram?
- a type of scan used to assess the shape of the uterus and the patency of fallopian tubes
- helps with diagnosis and has therapeutic benefit
- increases rate of conception
- tubal cannulation under xray guidance can be performed during this to open up tubes
How does a hysterosalpingogram work?
- small tube is inserted into cervix and a contrast medium is injected through the tube and fills the uterine cavity and fallopian tubes
- x-ray images are taken with contrast showing up outlining the uterus and tubes
- if contrast does not fill a tube, it suggests tubul obstruction
- as risk of infection with procedure, antibiotics are given prophylactically
What should be done before a hysterosalpingogram?
-screening for chlamydia and gonorrhoea
What does a laparoscopy and dye test involve?
- pt admitted for laparoscopy, during procedure dye is injected into the uterus and should be seen entering the fallopian tubes and spilling out at the ends of the tubes
- this will not me seen if there is tubal obstruction
- during laparoscopy, surgeon can also assess for endometriosis or pelvic adhesions and treat these
What are the management options when anovulation is the cause of infertility?
- weight loss for overweight pts with PCOS
- clomifene may be used to stimulate ovulation
- letrozole (aromatase inhibitor) may be used instead of clomifene
- gonadotropins may be used to stimulate ovulation in women resistant to clomifene
- ovarian drilling may be used in PCOS
- meftormin may be used where there is insulin insensitivity and obesity
What is clomifene?
- a selective oestrogen receptor modulator
- given on days 2 to 6 of cycle
- stops oestrogen negative feedback leading to higher GnRH and LH + FSH
What are the management options when tubal factors are the cause of infertility?
The options for women with alterations to the fallopian tubes that prevent the ovum from reaching the sperm and uterus include:
- Tubal cannulation during a hysterosalpingogram
- Laparoscopy to remove adhesions or endometriosis
- In vitro fertilisation (IVF)
What are the management options when uterine factors are the cause of infertility?
-Surgery may be used to correct polyps, adhesions or structural abnormalities affecting fertility.
What are the management options when Sperm Problems are the cause of infertility?
- surgical sperm retrieval s used when there is a blockage somewhere along the vas deferens preventing sperm from reaching the ejaculated semen
- Surgical correction of an obstruction in the vas deferens may restore male fertility
- Intra-uterine insemination
- Intracytoplasmic sperm injection (ICSI)
- Donor insemination
