Human Fertility and InfertilityPart 2- Definition, Causes and Investigations

Question 1

what is the clinical definition (WHO) of infertility?

Answer 1

Inability to conceive over a 12 month period despite exposure to regular, unprotected intercourse. Represents a prognosis based approach and provides practical guidance on when to initiate investigations

After a year doesn’t necessarily mean the couple are in fertile but should be referred for appropriate management

Question 2

what is teh epidemiological definition (WHO) of infertility?

Answer 2

Lack of conception after 2 years in women of reproductive age (15-49 years) who are at a risk of becoming pregnant (sexually active, not using contraception)

Question 3

what is the demographic definition of infertility?

Answer 3

Inability to become pregnant with a live birth, within 5 years of exposure, based upon a consistent union status, lack of contraceptive use, non-lactation and continuation of a desire for a child

Question 4

what are the global infertility rates?

Answer 4

WHO states that 10% women globally are affected based on the demographic definition but this is likely underestimated

Main challenges in generating true estimates of infertility is inconsistencies in the definition used to calculate the prevalence

Overall, 1in 7 couples in the western world and 1in 4 couples in the developing countries are affected

Question 5

when should you refer someone with infertility issues?

Answer 5

no conception after one year of regular unprotected intercourse

refferal earlier if - age >35 years, known cause for infertility

Question 6

what are the different causes of infertility

Answer 6

Primary - never managed to have a pregnancy or father never fathered a child

Secondary - couple have had a pregnancy before or in a previous relation

need to find where the problem is and if it is the male, female or both

Question 7

what may the causes of female infertility be?

Answer 7

Major proportion related to ovulation problems

In a small proportion we may not find any of these

Question 8

what are the causes of male infertility?

Answer 8

In men problem may be with hormone production which control sperm release from testicle

Or problem within testicle

May be a blockage in transport of sperm or outflow tract

May be ejaculation or erection problems stopping ejaculation into female tract

1 in 4 we won find a definite reasons

Question 9

Investigating Infertility - what questions should be asked and investigated?

Answer 9

• Are eggs available?
• Are sperm available?
• Can they meet?
• Any other factor ?

Question 10

are eggs avalible? how do you investigate this?

Answer 10

Age (egg count declines with steep decline over 35 years old)

Ovarian reserve test - blood test and scan

Blood test- FSH, Day 1-D5 of cycle (<10 iu/L)

AMH (antimalarian hormone, sensitive test and any time in the cycle and gives indication if ovarian reserve is satisfactory) (5.0-25.0pmol/L)

UltrasoundScan - Antral follicular count

Question 11

what methods can couples use to tell if ovulation is happening?

(picture hsowing LH kit)

Commonly available, Measuring peak of hormone LH mid cycle, Like pregnancy test, Drop of urine

Answer 11

natural methods (BBT (basal body temperature), cervical mucus)

LH ovulation kits

ovulation calendar (now mobile apps)

(Maximum cervical mucus discharge is maximum around time of ovulation)

Question 12

what are methods used ot investigate if ovulation is happening?

Answer 12

Day 21 serum progesterone (hormone level at its peak and any levels over 20 suggest ovulatory cycle)

Question 13

how is an ovulation diagnosis made?

Answer 13

Progesterone levels taken at appropriate time - day 21 only if 28/30 day cycle

Levels > 20nmol/l show satisfactory ovulation

Question 14

how do you ceck if sperm are avalible?

Answer 14

semen analysis

If parameters are lower then doesn’t mean infertility but just lower fertility

Question 15

Can egg and sperm meet? what things do you need to check?

Answer 15

Intercourse

Patent fallopian tubes

No painful intercourse or male doesn’t have erection or ejaculatory problems

Question 16

How do you check fallopian tube patency?

Answer 16

If no pelvic infection or gynaecological problem in past - Hysterosalpingogram(HSG) (use this one if no problems in past)

If any of above - Laparoscopic dye test

Question 17

what is a Hysterosalpingography (HSG)?

Answer 17

Small fine plastic catheter put through cervix and dye and x-ray taken

a radiologic procedure to investigate the shape of the uterine cavity and the shape and patency of the fallopian tubes. This means it is a special x-ray using dye to look at the womb and Fallopian tubes

Question 18

what is Laparoscopy?

Answer 18

Under general anaesthetic

Question 19

what are some other tests that could be done?

Answer 19

• Serum prolactin
• Thyroid function test
• Chlamydia screening
• Pelvic Ultrasound for uterine problems
• Also check- Rubella immunity, Cervical smear uptodate

Question 20

Conclusion:

Different definitions based on the ______

Refer after one year of trying or earlier based on female ___ or known ________ cause

Investigations to assess ovarian _______, ovulation, sperm production, fallopian tube _______ and uterine cavity

Cause identified could be female, male, combined or ________

Management tailored to the _______

Answer 20

context

age

infertility

reserve

patency

unexplained

diagnosis