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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
INFERTILITY
  • Assessment and treatment of patients with fertility problems

Dr Nitu Raje-Ghatge

why learn about it
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 it3
Why learn about it..

Expectations from secondary care services!

Inappropriate timing of referrals (early/late)

Incomplete /inadequate investigations

what is infertility
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
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/SECONDARY INFERTILITY
  • PRIMARY – Couple without a prior pregnancy
  • SECONDARY – Couple with previous pregnancy including miscarriage/ectopic.
etiology
Etiology:
  • Male factors
  • Female factors
  • Unexplained -20%
  • Mixed – 15%
slide8
Male

Account for 25%

  • Hypogonadotrophic hypogonadism
  • Obstructive azoospermia

Surgery

  • Erectile dysfunction
  • Anatomical

- Hypospadias

- Undescended/

maldescended testis

female
Female
  • Peritoneal factors 40%,

- Endometriosis.

  • Tubal blockage 20%.
etiology female
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.

history taking female
History taking (female)
  • Symptoms (past or present)

- P I D / STD,

- dysparenuria

- galactorrhoea,

- thyroid symptoms

  • Obstetric history
history taking female13
History taking (female)
  • Menstrual history

- irregularities

  • Surgical history

– D & C, abdominal/pelvic surgery

  • Contraception

- IUCDs

  • Cervical smear
history taking male
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 male15
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
IN BOTH
  • Smoking
  • Alcohol intake
  • Psychological factors
examination
EXAMINATION
  • General health and nutritional status
  • BMI

<19 (F)

> 29.(M/F)

  • SSC
female18
Female:
  • Hirsuitism, galactorrhoea
  • Bimanual examination

- adnexal masses (tubo/ovarian, ovarian cyst)

- tenderness (PID/ endometriosis)

- Uterine fibroids

slide19
Male
  • Hypospadias
  • Size and consistency of each testicle and epididymis;
  • Presence of varicocele or hernia;
  • Size of prostate.
  • Gynaecomastia
now what
Now what??

Investigate

Or

Refer

early referral if
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..
investigations
Primary care

Female

Assess ovulation.

Other hormonal tests

Tests for PID

Male

Sperm analysis

Secondary care

Tubal patency

Uterine abnormality

Investigations
assessing ovulation
Assessing ovulation

Do if

  • regular cycles with > 1 year of infertility
  • irregular cycles

1) Serum progesterone

2) LH/FSH levels

investigations female
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

assessing ovulation26
Assessing ovulation

2) LH/FSH levels

High levels – poor ovarian function

High LH compared to FSH -PCOS

other hormonal tests
Other hormonal tests
  • E2, Testosterone levels – PCOS
  • Prolactin ONLY if

- ovulation problems

- galactorrhoea,

- pituitary problem.

other hormonal tests28
Other hormonal tests
  • Thyroid tests

- only with symptoms/ signs

  • Other androgen profile (DHEAS,

Androstenedione, SBHG)

– as per etiology

tests for pid
Tests for PID
  • HVS
  • Chlamydia screening
don t forget
Don’t forget!!
  • Rubella status

- check immunity

- Vaccinate if non immune, avoid conception for 3 months

cervical hostility
Cervical hostility
  • Post coital test

- no longer recommended by NICE

  • Mucus invasion test

- doubtful significance

investigations male
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
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

tests for uterine tubal problems
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
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
Positive approach

Reassure about cumulative pregnancy rates

management in primary care38
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 care39
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
Management in secondary care
  • Depends upon the etiology..
hypogonadotrophic hypogonadism
Hypogonadotrophic hypogonadism
  • Pulsatile GnRH
  • Gonadotrophins with LH activity
  • Bromocriptine ( for hyperprolactinaemia)
ovarian dysfunction hypothalamic dysfunction
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
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
Others…

3) Gonadotrophins

4) Luteal phase support –

- progesterone,

- clomiphene

5) Laparoscopic ovarian drilling

peritoneal problems endometriosis
Peritoneal problems (endometriosis)
  • Laparoscopic surgical ablation/ resection of endometriosis + adhesiolysis
  • If ovarian endometriomas, laparoscopic cystectomy
uterine tubal factors
Uterine/ tubal factors
  • Tubal factors:

- Laparoscopic tubal surgery/ tubal microsurgery

- Salpingography + tubal catheteristion

- Hysteroscopic tubal cannulation

  • Uterine factors

- hysteroscopic adhesiolysis

- myomectomy

assisted reproduction techniques
Assisted reproduction techniques
  • Intra uterine insemination (IUI)
in vitrio fertilisation
In vitrio fertilisation
  • Intracytoplasmic sperm injection (ICSI)
  • Donor insemination
  • Oocyte donation
acon at crh
ACON at CRH
  • Satellite IVF unit
  • Counselling, monitoring and most of treatment , except egg retrieval and embryo transfer.
central unit
Central unit
  • Clarendon Wing, LGI
  • SJUH, Leeds
  • CARE, Manchester
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