INFERTILITY

1
INFERTILITY

• Assessment and treatment of patients with
  fertility problems
• Dr Nitu Raje-Ghatge

2
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

3
Why learn about it..

• Expectations from secondary care services!
• Inappropriate timing of referrals (early/late)
• Incomplete /inadequate investigations

4
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.

5
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.

6
PRIMARY/SECONDARY INFERTILITY

• PRIMARY Couple without a prior pregnancy
• SECONDARY Couple with previous pregnancy
  including miscarriage/ectopic.

7
Etiology

• Male factors
• Female factors
• Unexplained -20
• Mixed 15

8
Male

• Account for 25
• Hypogonadotrophic hypogonadism
• Obstructive azoospermia
• Surgery
• Erectile dysfunction
• Anatomical
• - Hypospadias
• - Undescended/
• maldescended testis

9
Female

• Peritoneal factors 40,
• - Endometriosis.
• Tubal blockage 20.

10
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.

11

• Fertility may be impaired in poorly controlled
  diabetes.

12
History taking (female)

• Symptoms (past or present)
• - P I D / STD,
• - dysparenuria
• - galactorrhoea,
• - thyroid symptoms
• Obstetric history

13
History taking (female)

• Menstrual history
• - irregularities
• Surgical history
• D C, abdominal/pelvic surgery
• Contraception
• - IUCDs
• Cervical smear

14
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

15
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

16
IN BOTH

• Smoking
• Alcohol intake
• Psychological factors

17
EXAMINATION

• General health and nutritional status
• BMI
• lt19 (F)
• gt 29.(M/F)
• SSC

18
Female

• Hirsuitism, galactorrhoea
• Bimanual examination
• - adnexal masses (tubo/ovarian, ovarian cyst)
• - tenderness (PID/ endometriosis)
• - Uterine fibroids

19
Male

• Hypospadias
• Size and consistency of each testicle and
  epididymis
• Presence of varicocele or hernia
• Size of prostate.
• Gynaecomastia

20
Now what??

• Investigate
• Or
• Refer

21
Early referral if..

• Male
• Undescended testes
• Previous genital pathology
• Previous urogenital surgery
• In Both
• Prior treatment for cancer
• HIV, Hep B, Hep C

• Female
• Age gt35 years
• Amenorrhoea/ oligo menorrhoea
• PID
• Abnormal pelvic exam

22
Investigations

• Primary care
• Female
• Assess ovulation.
• Other hormonal tests
• Tests for PID
• Male
• Sperm analysis

• Secondary care
• Tubal patency
• Uterine abnormality

23
Assessing ovulation

• Do if
• regular cycles with gt 1 year of infertility
• irregular cycles
• 1) Serum progesterone
• 2) LH/FSH levels

24
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

25
Interpretation of test
26
Assessing ovulation

• 2) LH/FSH levels
• High levels poor ovarian function
• High LH compared to FSH -PCOS

27
Other hormonal tests

• E2, Testosterone levels PCOS
• Prolactin ONLY if
• - ovulation problems
• - galactorrhoea,
• - pituitary problem.

28
Other hormonal tests

• Thyroid tests
• - only with symptoms/ signs
• Other androgen profile (DHEAS,
• Androstenedione, SBHG)
• as per etiology

29
Tests for PID

• HVS
• Chlamydia screening

30
Dont forget!!

• Rubella status
• - check immunity
• - Vaccinate if non immune, avoid conception for
  3 months

31
Cervical hostility

• Post coital test
• - no longer recommended by NICE
• Mucus invasion test
• - doubtful significance

32
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

33
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 - lt1 million/ml
• Anti sperm antibody tests- not recommended by NICE

34
Investigations in secondary care
35
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

36
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

37
Positive approach

• Reassure about cumulative pregnancy rates

38
Management in primary care

• Lifestyle changes
• - Weight reduction,
• BMI 19-29
• - Smoking cessation- offer support
  groups
• - Alcohol reduction
• lt1-2 units/week for women
• lt3-4 units/week for men
• - S I every 2-3 days
• - Information about OTC/ recreational
  drugs

39
Management in primary care

• Pre conceptual advice
• - Folic acid supplementation
• - Rubella status
• - Cervical screening
• Management of erectile dysfunction
• - psychosexual couselling
• - drugs

40
Management in secondary care

• Depends upon the etiology..

41
Hypogonadotrophic hypogonadism

• Pulsatile GnRH
• Gonadotrophins with LH activity
• Bromocriptine ( for hyperprolactinaemia)

42
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

43
Ovulatory dysfunction- treatment

• 2) Metformin
• - not licensed for ovulatory disorders in UK
• - used 2nd line with Clomiphene in
• - anovulatory women with PCOD
• BMI gt25
• no response to CC

44
Others

• 3) Gonadotrophins
• 4) Luteal phase support
• - progesterone,
• - clomiphene
• 5) Laparoscopic ovarian drilling

45
Peritoneal problems (endometriosis)

• Laparoscopic surgical ablation/ resection of
  endometriosis adhesiolysis
• If ovarian endometriomas, laparoscopic cystectomy

46
Uterine/ tubal factors

• Tubal factors
• - Laparoscopic tubal surgery/ tubal
  microsurgery
• - Salpingography tubal catheteristion
• - Hysteroscopic tubal cannulation
• Uterine factors
• - hysteroscopic adhesiolysis
• - myomectomy

47
Assisted reproduction techniques

• Intra uterine insemination (IUI)

48
In vitrio fertilisation

• Intracytoplasmic sperm injection (ICSI)
• Donor insemination
• Oocyte donation

49
(No Transcript)
50
(No Transcript)
51
(No Transcript)
52
ACON at CRH

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

53
Central unit

• Clarendon Wing, LGI
• SJUH, Leeds
• CARE, Manchester

54
Questions..zzzz??