Infertility

Definitions

• Failure to conceive within 2 years of regular unprotected intercourse.

• Primary or secondary.

• 84% of couples will conceive within 1 year and 92% within 2 years.

ManagementHistory

• Couple should be seen together and reassured.

• Woman’s age and duration of infertility.• Any history suggestive of a cause.• Investigate after one year of failure to

conceive.• Investigate sooner if > 35 or history suggestive

of problems.

Examination

FemaleBMIHyperandrogenismGalactorrheaPelvic abnormalities

MaleAssess genitalia if history

suggestive or semenalysis abnormal

• Reassure women with regular cycles.• Advice re timing and frequency of intercourse.• Avoid alcohol, smoking, drugs.• Folic acid.• Weight.

Baseline investigations

Female• Follicular phase LH, FSH,

oestradiol• Luteal phase

progesterone• Rubella• Consider tubal patency

test (chlamydia test first)

Male• Semenalysis & repeat at

3 months if abnormal

• Volume >2ml• pH 7-8• Concentration >20 x 106/ml• Motility >50% forward & >25% with

rapid linear progress• Morphology > 15% normal• Alive > 50%• Antisperm antibodies Negative• WCC < 1x106

Treatment

Male Factor• Hypogonadotrphic hypogonadism –

gonadotrophins

• Obstructive azoospermia – surgical correction

• Correction of varicocele

Anovulation

• Clomiphene days 2-6 for up to 1 year. Monitor with ultrasound for 1st cycle.

• Gonadotrophins – FSH for 10 days followed by hCG.

• Ovarian drilling

• Metformin (evidence lacking)

Tubal Disease

• Ablate endometriosis at the time of laparoscopy

• Tubal surgery

• IVF

Intrauterine Insemination

• Used in unexplained or mild male factor infertility.

• Outcome may be no better than expectant management.

IVF

• Pituitary suppression – GnRH agonist• Superovulation – FSH (hyperstimulation)• hCG to mimic LH surge• Oocyte collection • Fertilisation & incubation (ICSI)• Embryo transfer 48-72 hours later• Luteal support with progesterone

• Take-home baby rate 20% per cycle.• Consider alternatives: oocyte/sperm donation

surrogacy adoption