Post on 18-Jan-2018
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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
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
Investigations
Primary care
FemaleAssess ovulation.Other hormonal testsTests for PID
MaleSperm analysis
Secondary care
Tubal patency Uterine abnormality
Assessing ovulation
Do if regular cycles with > 1 year of infertility irregular cycles
1) Serum progesterone2) 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
Interpret after next LMP known
<16 nmol/l
Repeat in another cycle.Refer if consistently low
>16 nmol/l but <30 nmol/l
Repeat in another cycle.Refer if same/lower
>30 nmol/l
Consider as proof of adequate ovulation
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
Management in primary care
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
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) Gonadotrophins4) 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??