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INFERTILITY - PowerPoint PPT Presentation

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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 l.jpg


  • Assessment and treatment of patients with fertility problems

    Dr Nitu Raje-Ghatge

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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

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Why learn about it..

Expectations from secondary care services!

Inappropriate timing of referrals (early/late)

Incomplete /inadequate investigations

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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.


    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.

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Natural conception rates:

80% of couples will be pregnant after 12


50% of remaining will conceive during a

2nd year ( hence cumulative rate 90%)

50% in the following 4 years.

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  • PRIMARY – Couple without a prior pregnancy

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

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  • Male factors

  • Female factors

  • Unexplained -20%

  • Mixed – 15%

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Account for 25%

  • Hypogonadotrophic hypogonadism

  • Obstructive azoospermia


  • Erectile dysfunction

  • Anatomical

    - Hypospadias

    - Undescended/

    maldescended testis

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  • Peritoneal factors 40%,

    - Endometriosis.

  • Tubal blockage 20%.

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Etiology (female)

  • Ovulatory dysfunction 15-20%

    - Hypothalamic/hypogonadotrophic


    - Hypothalamic pituitary dysfunction


    - Ovarian failure

  • Uterine cavity abnormalities

    - Asherman's syndrome

    - Uterine fibroids.

  • Cervical hostility 5-10%,

    - Infection

    - Female sperm antibodies.

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Fertility may be impaired in poorly controlled diabetes.

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History taking (female)

  • Symptoms (past or present)

    - P I D / STD,

    - dysparenuria

    - galactorrhoea,

    - thyroid symptoms

  • Obstetric history

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History taking (female)

  • Menstrual history

    - irregularities

  • Surgical history

    – D & C, abdominal/pelvic surgery

  • Contraception

    - IUCDs

  • Cervical smear

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History taking (male)

  • Symptoms

    h/o genital tract infection e.g. mumps orchitis, prostatitis

  • Surgical history

    - Hernia repair

    - Testicular surgery for torsion/ undescended /maldescended


    - Prostate surgery

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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

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  • Smoking

  • Alcohol intake

  • Psychological factors

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  • General health and nutritional status

  • BMI

    <19 (F)

    > 29.(M/F)

  • SSC

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  • Hirsuitism, galactorrhoea

  • Bimanual examination

    - adnexal masses (tubo/ovarian, ovarian cyst)

    - tenderness (PID/ endometriosis)

    - Uterine fibroids

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  • Hypospadias

  • Size and consistency of each testicle and epididymis;

  • Presence of varicocele or hernia;

  • Size of prostate.

  • Gynaecomastia

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Now what??




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Age >35 years

Amenorrhoea/ oligo menorrhoea


Abnormal pelvic exam


Undescended testes

Previous genital pathology

Previous urogenital surgery

In Both

Prior treatment for cancer

HIV, Hep B, Hep C

Early referral if..

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Primary care


Assess ovulation.

Other hormonal tests

Tests for PID


Sperm analysis

Secondary care

Tubal patency

Uterine abnormality


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Assessing ovulation

Do if

  • regular cycles with > 1 year of infertility

  • irregular cycles

    1) Serum progesterone

    2) LH/FSH levels

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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

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Interpretation of test

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Assessing ovulation

2) LH/FSH levels

High levels – poor ovarian function

High LH compared to FSH -PCOS

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Other hormonal tests

  • E2, Testosterone levels – PCOS

  • Prolactin ONLY if

    - ovulation problems

    - galactorrhoea,

    - pituitary problem.

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Other hormonal tests

  • Thyroid tests

    - only with symptoms/ signs

  • Other androgen profile (DHEAS,

    Androstenedione, SBHG)

    – as per etiology

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Tests for PID

  • HVS

  • Chlamydia screening

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Don’t forget!!

  • Rubella status

    - check immunity

    - Vaccinate if non immune, avoid conception for 3 months

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Cervical hostility

  • Post coital test

    - no longer recommended by NICE

  • Mucus invasion test

    - doubtful significance

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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

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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

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Investigations in secondary care

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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

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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

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Positive approach

Reassure about cumulative pregnancy rates

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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

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Management in primary care

  • Pre conceptual advice

    - Folic acid supplementation

    - Rubella status

    - Cervical screening

  • Management of erectile dysfunction

    - psychosexual couselling

    - drugs

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Management in secondary care

  • Depends upon the etiology..

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Hypogonadotrophic hypogonadism

  • Pulsatile GnRH

  • Gonadotrophins with LH activity

  • Bromocriptine ( for hyperprolactinaemia)

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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

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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

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3) Gonadotrophins

4) Luteal phase support –

- progesterone,

- clomiphene

5) Laparoscopic ovarian drilling

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Peritoneal problems (endometriosis)

  • Laparoscopic surgical ablation/ resection of endometriosis + adhesiolysis

  • If ovarian endometriomas, laparoscopic cystectomy

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Uterine/ tubal factors

  • Tubal factors:

    - Laparoscopic tubal surgery/ tubal microsurgery

    - Salpingography + tubal catheteristion

    - Hysteroscopic tubal cannulation

  • Uterine factors

    - hysteroscopic adhesiolysis

    - myomectomy

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Assisted reproduction techniques

  • Intra uterine insemination (IUI)

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In vitrio fertilisation

  • Intracytoplasmic sperm injection (ICSI)

  • Donor insemination

  • Oocyte donation

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  • Satellite IVF unit

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

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Central unit

  • Clarendon Wing, LGI

  • SJUH, Leeds

  • CARE, Manchester

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