Subfertility

Question 1

Subfertility - hx

Answer 1

Combined

1. Age, duration of infertility
2. Primary (never been pregnant) vs. secondary infertility (has been pregnant, no matter the outcome)
3. Pregnancies outside current partnership
4. Frequency of sexual intercourse, use of contraception, timing with ovulation
5. Concerns/how they feel about the current situation

Male

1. STIs
2. Mumps as an adult
3. Operations (e.g. repair of inguinal hernias, orchidopexy)
4. Drugs (e.g. antimitotic agents [chemotherapy], beta blockers)
5. Excess alcohol, smoking hx, hx recreational drug use. Occupational/leisure pursuits that could compromise fertility, e.g. exercise training

Female

1. Menstrual cycle hx
   a. Regularity, number of days for period, length, bleeding heavy or not
   b. Primary/secondary dysmenorrhoea
   c. Changes in vaginal discharge
   d. Premenstrual symptoms
2. Reproductive hx (?)
3. RFs for pelvic infection = STIs, IUDs, previous pelvic surgery
4. Symptoms of endometriosis = secondary dysmenorrhoea, dyspareunia, dyschezia
5. Medications, smoking, alcohol, illicit drug use

Question 2

Subfertility - ex

Answer 2

Male (2)

1. General appearance, signs of hypoandrogenism (e.g. loss of secondary sex characteristics)
2. Examination of genitalia
   a. Size and consistency of testicles
   b. Presence of vas deferens +/- varicocele +/- hydrocele +/- hernia

Female (5)

1. Secondary sexual development
2. Evidence of PID (abdominal examination to elicit site and severity of pain, speculum and vaginal examination to ax for adnexal masses, vaginal discharge or cervical excitation)
3. Evidence of endometriosis (bimanual pelvic examination for adnexal masses/tenderness, nodules/tenderness in posterior vaginal fornix or uterosacral ligaments, fixed retroverted uterus, rectovaginal nodules, speculum examination of vagina and cervix - rarely, lesions may be visible)
4. On pelvic examination, exclude fibroids, ovarian masses, nodules or reduced mobility of pelvic organs; note size, shape, position and mobility of uterus, as well as size of ovaries if palpable
5. Pap smear if due

Question 3

Subfertility - ix (standard), combined 5

Answer 3

Male (2)

1. Semen analysis (if specimen suboptimal, repeat test after 4-6 weeks before making final ax of quality)
2. IBT (immunobead test for anti-sperm antibodies - ?)

Female (3)

3. Serum FSH (ideally combined with estradiol level)
4. Midluteal progesterone level
5. Antenatal screening tests (rubella immunity, routine genital tract swab tests - ?)

Question 4

Subfertility - ix (further - if standard ix abnormal)

Answer 4

Male (5)

1. Serum FSH, LH, testosterone and prolactin (determining if etiology is primary or secondary testicular dysfunction)
2. If severe oligospermia, consider chromosomal analysis
3. Fructose concentration in semen (fructose negative semen indicates absence of seminal vesicles or obstruction of vas deferens)
4. If azoospermia + absent vas deferens, test for mutations of CFTR gene
5. Testicular biopsy rarely required

Female (5)
If ovulation cannot be confirmed from midluteal serum progesterone level (see above), important to exclude thyroid dysfunction, hyperprolactinaemia, PCOS and premature ovarian insufficiency.
1. Thyroid dysfunction = TFTs
2. Hyperprolactinaemia = serum prolactin
3. PCOS = transvaginal pelvic US scan, androgen screen, elevated follicular phase LH and FSH
4. Ovarian failure (i.e. ovarian reserve) = elevated serum FSH and low serum estradiol
5. Testing for tubal patency (if woman is ovulatory and no other cause of infertility apparent)
- Laparoscopy, hysteroscopy, dye studies, D&C or hysterosalpingogram