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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Dr Nitu Raje-Ghatge
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
Expectations from secondary care services!
Inappropriate timing of referrals (early/late)
Incomplete /inadequate investigations
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.
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.
Account for 25%
- Hypothalamic pituitary dysfunction
- Ovarian failure
- Asherman's syndrome
- Uterine fibroids.
- Female sperm antibodies.
- P I D / STD,
- thyroid symptoms
– D & C, abdominal/pelvic surgery
h/o genital tract infection e.g. mumps orchitis, prostatitis
- Hernia repair
- Testicular surgery for torsion/ undescended /maldescended
- Prostate surgery
- exposure to lead, cadmium
- Sulphasalazine – impairs spermatogenesis
- Phenothiazines/ typical antipsychotics/ metoclopramide
increase prolactin levels
- adnexal masses (tubo/ovarian, ovarian cyst)
- tenderness (PID/ endometriosis)
- Uterine fibroids
Age >35 years
Amenorrhoea/ oligo menorrhoea
Abnormal pelvic exam
Previous genital pathology
Previous urogenital surgery
Prior treatment for cancer
HIV, Hep B, Hep CEarly referral if..
Other hormonal tests
Tests for PID
1) Serum progesterone
2) LH/FSH levels
1) Serum progesterone
(mid luteal phase ie day 21 of 28 week cycle)
Timing is important!!!
till menstruation occurs
2) LH/FSH levels
High levels – poor ovarian function
High LH compared to FSH -PCOS
- ovulation problems
- pituitary problem.
- only with symptoms/ signs
– as per etiology
- check immunity
- Vaccinate if non immune, avoid conception for 3 months
- no longer recommended by NICE
- doubtful significance
Anti sperm antibody tests- not recommended by NICE
Done only when ovulation tests/Sperm tests normal.
Choice of tests depends upon co morbidities
Principles of care
Reassure about cumulative pregnancy rates
- Weight reduction,
- 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 drugsManagement in primary care
- Folic acid supplementation
- Rubella status
- Cervical screening
- psychosexual couselling
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
- not licensed for ovulatory disorders in UK
- used 2nd line with Clomiphene in
- anovulatory women with PCOD
+ BMI >25
+ no response to CC
4) Luteal phase support –
5) Laparoscopic ovarian drilling
- Laparoscopic tubal surgery/ tubal microsurgery
- Salpingography + tubal catheteristion
- Hysteroscopic tubal cannulation
- hysteroscopic adhesiolysis