Fertility and Subfertility (2)

Question 1

In who should investigations into infertility be started?

What are the causes?

Answer 1

➊ Couples who’ve been struggling to actively conceive for 12 months

➋ • Sperm problems – 30%
• Ovulation problems – 25%
• Unexplained – 20%
• Tubal problems – 15%
• Uterine problems – 10%
• Genetics

Question 2

What’s some general advice you can give to these couples?

Answer 2

• Woman should be taking 400mcg Folic acid OD
• Aim for healthy BMI – don’t excessively exercise
• Avoid smoking and drinking excessively
• Reduce stress
• Avoid timing intercourse – Not necessary or recommended as it can lead to increased stress and pressure in the relationship

Question 3

Investigations:
What should be done for both the male and female?

What should be done for the male?

What should be done for the female?

Which imaging and special tests should be done?

Answer 3

➊ Chlamydia and Gonorrhoea screen – PID can cause tubal adhesions

➋ Semen analysis

➌ • BMI – Low could indicate anovulation, High could indicate PCOS
• Female hormonal testing – LH, FSH, Progesterone, AMH, Thyroid, Prolactin
‣ High LH suggests PCOS
‣ High FSH suggest poor ovarian reserve (follicular count)
‣ Rise in Progesterone suggests ovulation has occurred
‣ High AMH suggests good ovarian reserve (follicular count)

➍ • Pelvic US – look for any structural abnormalities
• Hysterosalpingogram – look at tubal patency
• Laparoscopy and Dye test – look for tubal patency, adhesions and endometriosis

Question 4

Management:
What may be done if a sperm problem?

What may be done if an ovulation problem?

What may be done if a tubal problem?

What may be done if a uterine problem?

Answer 4

➊ • Surgical sperm retrieval
• Surgical correction of obstruction in vas deferens
• Intra-uterine insemination – collecting and separating out the high-quality sperm, then injecting them directly into the uterus
• Sperm donation

➋ • Weight loss for PCOS pts can restore ovulation
• Clomifene to stimulate ovulation – Letrozole and Gonadotropins are other options
• Ovarian drilling in PCOS – reduces testosterone production, therefore stimulating ovulation

➌ • Tubal cannulation
• Laparoscopy to remove adhesions and endometriosis
• IVF

➍ Surgery for polyps, adhesions and other structural problems affecting fertility