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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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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

secondary care investigations

Primary care management

Knowledge of specialist treatments

and surgical procedures


Why learn about it..

Expectations from secondary care services!

Inappropriate timing of referrals (early/late)

Incomplete /inadequate investigations


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.


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.


PRIMARY/SECONDARY INFERTILITY

  • PRIMARY – Couple without a prior pregnancy

  • SECONDARY – Couple with previous pregnancy including miscarriage/ectopic.


Etiology:

  • Male factors

  • Female factors

  • Unexplained -20%

  • Mixed – 15%


Male

Account for 25%

  • Hypogonadotrophic hypogonadism

  • Obstructive azoospermia

    Surgery

  • Erectile dysfunction

  • Anatomical

    - Hypospadias

    - Undescended/

    maldescended testis


Female

  • Peritoneal factors 40%,

    - Endometriosis.

  • Tubal blockage 20%.


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.


Fertility may be impaired in poorly controlled diabetes.


History taking (female)

  • Symptoms (past or present)

    - P I D / STD,

    - dysparenuria

    - galactorrhoea,

    - thyroid symptoms

  • Obstetric history


History taking (female)

  • Menstrual history

    - irregularities

  • Surgical history

    – D & C, abdominal/pelvic surgery

  • Contraception

    - IUCDs

  • Cervical smear


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


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


IN BOTH

  • Smoking

  • Alcohol intake

  • Psychological factors


EXAMINATION

  • General health and nutritional status

  • BMI

    <19 (F)

    > 29.(M/F)

  • SSC


Female:

  • Hirsuitism, galactorrhoea

  • Bimanual examination

    - adnexal masses (tubo/ovarian, ovarian cyst)

    - tenderness (PID/ endometriosis)

    - Uterine fibroids


Male

  • Hypospadias

  • Size and consistency of each testicle and epididymis;

  • Presence of varicocele or hernia;

  • Size of prostate.

  • Gynaecomastia


Now what??

Investigate

Or

Refer


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..


Primary care

Female

Assess ovulation.

Other hormonal tests

Tests for PID

Male

Sperm analysis

Secondary care

Tubal patency

Uterine abnormality

Investigations


Assessing ovulation

Do if

  • regular cycles with > 1 year of infertility

  • irregular cycles

    1) Serum progesterone

    2) LH/FSH levels


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


Interpretation of test


Assessing ovulation

2) LH/FSH levels

High levels – poor ovarian function

High LH compared to FSH -PCOS


Other hormonal tests

  • E2, Testosterone levels – PCOS

  • Prolactin ONLY if

    - ovulation problems

    - galactorrhoea,

    - pituitary problem.


Other hormonal tests

  • Thyroid tests

    - only with symptoms/ signs

  • Other androgen profile (DHEAS,

    Androstenedione, SBHG)

    – as per etiology


Tests for PID

  • HVS

  • Chlamydia screening


Don’t forget!!

  • Rubella status

    - check immunity

    - Vaccinate if non immune, avoid conception for 3 months


Cervical hostility

  • Post coital test

    - no longer recommended by NICE

  • Mucus invasion test

    - doubtful significance


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


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


Investigations in secondary care


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


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


Positive approach

Reassure about cumulative pregnancy rates


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


Management in primary care

  • Pre conceptual advice

    - Folic acid supplementation

    - Rubella status

    - Cervical screening

  • Management of erectile dysfunction

    - psychosexual couselling

    - drugs


Management in secondary care

  • Depends upon the etiology..


Hypogonadotrophic hypogonadism

  • Pulsatile GnRH

  • Gonadotrophins with LH activity

  • Bromocriptine ( for hyperprolactinaemia)


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


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


Others…

3) Gonadotrophins

4) Luteal phase support –

- progesterone,

- clomiphene

5) Laparoscopic ovarian drilling


Peritoneal problems (endometriosis)

  • Laparoscopic surgical ablation/ resection of endometriosis + adhesiolysis

  • If ovarian endometriomas, laparoscopic cystectomy


Uterine/ tubal factors

  • Tubal factors:

    - Laparoscopic tubal surgery/ tubal microsurgery

    - Salpingography + tubal catheteristion

    - Hysteroscopic tubal cannulation

  • Uterine factors

    - hysteroscopic adhesiolysis

    - myomectomy


Assisted reproduction techniques

  • Intra uterine insemination (IUI)


In vitrio fertilisation

  • Intracytoplasmic sperm injection (ICSI)

  • Donor insemination

  • Oocyte donation


ACON at CRH

  • Satellite IVF unit

  • Counselling, monitoring and most of treatment , except egg retrieval and embryo transfer.


Central unit

  • Clarendon Wing, LGI

  • SJUH, Leeds

  • CARE, Manchester


Questions…..zzzz??


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