Infertility/Subfertility

Question 1

Definition of subfertility

Answer 1

• The inability to conceive after 12 months of regular unprotected intercourse (~15%)

Question 2

Aetiology of subfertility

Answer 2

• Ovulatory dysfunction (anovulation)
  
  • Age
  • PCOS
  • Hypothalamic hypogonadism
  • Hyperprolactinaemia
  • Thyroid disease
• Tubal damage
  
  • Infection (PID)
    
    • Chlamydia
    • Gonnorhoea
  • Endometriosis
  • Previous surgery or sterilisation
• Male subfertility
  
  • Sperm count
  • Volume
  • Motility
• Unexplained

Question 3

Risk factors for subfertility

Answer 3

• Age >35 years
• Hx of STIs
• Very high/low body fat (ovulatory dysfunction)
• Smoking (accelerated menopause)

Question 4

Fertility history

Answer 4

• General health
  
  • What is your general health like?
    
    • Diabetes
    • Thyroid
  • Do you take any regular medications?
    
    • Folic acid
  • Smoking
  • Alcohol
  • Exercise
  • Diet (we will check your BMI)
• Menstrual history
  
  • Is your cycle regular?
  • Any irregular bleeding?
    
    • PCOS
    • Hyperprolactinaemia
• Gynae Hx
  
  • Are you up to date with your smear? Last one? Result?
  • Have you ever been tested for STI (chlamydia or gonorrhoea)? Receive antibiotics?
  • Pain (PID/endometriosis)
  • Have you ever had any pelvic surgery?
• Fertility Hx
  
  • How long have you been trying?
  • Were you using any contraception prior to this?
  • How many times a week do you have sex? Any problems with intercourse?
  • Have you ever been pregnant in the past?
  • Has your partner ever fathered any children?

Question 5

Investigations for subfertility

Answer 5

• Semen analysis
• Luteal-phase progesterone (corpus luteum)
  
  • Measured 7 days after ovulation (21 days)
• Urinary LH (surge at ovulation)
• Transvaginal US
  
  • PCOS
  • Hydrosalpinx
  • Fibroids etc.
• Hysterosalpingogram (patent/blocked)

Question 6

Management of subfertility

Answer 6

• Ovulation dysfunction
  
  • Hypothalamic hypogonadism
    
    • Increase weight
    • Moderate exercise levels
    • Pulsatile GnRH or gonadotrophins with LH activity to induce ovulation
  • PCOS
    
    • Clomifene (anti-oestrogen)
      
      • Days 2-6
    • Metformin
    • Weight loss
  • Hyperprolactinaemia
    
    • Bromocriptine (dopamine agonist)
• Assisted conception