INFERTILITY Assessment and treatment of patients with fertility problems Dr Nitu Raje-Ghatge.
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Transcript of INFERTILITY Assessment and treatment of patients with fertility problems Dr Nitu Raje-Ghatge.
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INFERTILITY
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.
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.
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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.
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PRIMARY/SECONDARY INFERTILITY
PRIMARY – Couple without a prior pregnancy
SECONDARY – Couple with previous pregnancy including miscarriage/ectopic.
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Etiology:
Male factors Female factors Unexplained -20% Mixed – 15%
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Male
Account for 25% Hypogonadotrophic
hypogonadism Obstructive azoospermia Surgery Erectile dysfunction Anatomical - Hypospadias - Undescended/ maldescended testis
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Female
Peritoneal factors 40%,
- Endometriosis.
Tubal blockage 20%.
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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.
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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 testis - 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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IN BOTH
Smoking Alcohol intake Psychological factors
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EXAMINATION
General health and nutritional status BMI <19 (F) > 29.(M/F) SSC
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Female:
Hirsuitism, galactorrhoea Bimanual examination - adnexal masses (tubo/ovarian, ovarian cyst) - tenderness (PID/ endometriosis) - Uterine fibroids
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Male
Hypospadias Size and consistency of each testicle and
epididymis; Presence of varicocele or hernia; Size of prostate. Gynaecomastia
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Now what??
Investigate
Or
Refer
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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
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Investigations
Primary care
FemaleAssess ovulation.Other hormonal testsTests for PID
MaleSperm 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 progesterone2) LH/FSH levels
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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
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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
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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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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
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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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Others…
3) Gonadotrophins4) 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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ACON at CRH
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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Questions…..zzzz??