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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