Subfertility B Y A L I S O N, B E N A N D J O H N

Subfertility B Y A L I S O N, B E N A N D J O H N

Contents Definition Causes Male Female Hx & Ex Investigations Treatment

Definition Failure to conceive after a year of frequent, unprotected communion. Affects 10-15% couples. Primary : woman who has never conceived Secondary : previously conceived but not delivered

Causes Both partners Mechanical difficulty in coitus inadequate penetration Separation Male Impotence Premature ejaculation Azoospermia/oligospermia Poor sperm motility <10% normal forms

History and examination for men History Length of time with partner Duration of sexual relationship Sexual history Frequency of intercourse, ejaculate quality Previous children +/- relationships Injury to reproductive system Orchitis (?mumps), herniae, varicocoele, STIs Examination Build and appearance Examination genitalia Hypospadia Discharge Testicle size (orchidometer), consistency, tenderness

Causes contd. Female Fallopian tubes?infection Ovarian dysfunction Ovulation may not occur Irregular ovulation PCOS / Hyperprolactinaemia Perimenopausal / Premature ovarian failure Intact hymen Inadequate sex education Congenital malformation of vagina or uterus

History for women History Age Length of time with partner Duration of sexual relationship Obstetric history including: Previous pregnancies, abortions, miscarriages, ectopics Menstrual Menarche, cycle and duration, regularity, Dysmenorrhoea, menorrhagia, recent change Discharge Quantity, quality PMH PCOS, PID, DM, CKD, STI, previous surgery to abdo/pelvis Sexual history Dyspareunia, frequency, success, etc. Contraception

Examination of female General examination BMI Physical development?endocrine disorders Abdomen Scars, tenderness, guarding, masses PV State of introitus, vaginismus Size and mobility of uterus Attempt palpation of ovaries (?PCOS)

Investigations for men Semen analysis Masturbated specimen Collected <2 hrs If oligo/azoospermia, cause must be found i.e. Klinefelters, 1 /2 Hypogonadism

Semen analysis (NICE guidelines 2013) Volume ph Sperm concentration Total sperm number Total mobility vitality Sperm morphology 1.5 ml or more 7.2 or more 15 spematozoa per ml or more 39 million per ejaculate or more 40% or more motile or 32% or more with progressive motility 58% or more live spermatozoa 4% or higher normal forms

Investigations for women Basal temperature charts Rarely used Ovulation predictor tests Urine LH Tubal patency Hysterosalpingography Hormone tests Serum progesterone 21-23 Should be x10 during ovulation LH, FSH, Testosterone 3-8 Ultrasound Anatomical structures

Treatment Correction of coital problems Explored sensitively Infertility in men Azoospermia absolute barrier Severe oligospermia near absolute barrier Correction of varicocoele doubles chances if oligospermia Donor insemination 65% success / 12 mth Epidydimal sperm recovery 30% per cycle

Treatment of infertility in women Anovulation Correct BMI to within 19.0-24.9 Clomifene induces ovulation >80% of women with hypothalamic amenorrhoea (particularly if progesterone test postive). Persistent anovulation specialist centre. Follitropin and hcg. 70% of amenorrhoea patients and 25% of oligomenorrhoea patients will conceive. Asherman s Syndrome Removal of scar tissue

Treatment of infertility in women Tubal damage Surgery Salpingostomy/fimbrioloysis 40% chance of conception. Reversal of tubal ligation 60%. IVF Less invasive, less risk of ectopic. Cervical hostility Condoms For 6 months to reduce antisperm antibodies Prednisolone 20mg BD Taken by the MAN for first 10 days of her cycle Introduce washed sperm into uterine cavity IVF

Assisted Reproductive Technology Intrauterine Insemination: Pregnancy rate 15%/cycle Sperm into uterus via long tube (turkey baster!) Some conditions have good success rate: Localised cervical/uterine problems Impotence Poor mobility Retrograde ejaculation Severe hypospadias Infrequent/absent sexual intercourse

Assisted Reproductive Technology IVF: Preganancy rate 10-25% (per cycle) Superovulation (using ovulatory drugs, FSH, GnRH agonist, hgc). Eggs extracted from ovaries (transvaginally). Eggs fertilised in vitro. 1-2 fertilised eggs transferred into uterus or tubes. Used for: Oligospermia Sperm antibodies present Endometriosis Damaged tubes Unexplained infertility

Assisted Reproductive Technology Intracytoplasmic Sperm Injection: Pregnancy >50% Sperm injected into ovum Useful for patients with oligospermia Third party assisted Primary ovarian failure Azoospermia Known genetic disease

References Hamilton-Fairley, D. (2008) Obstetrics and Gynaecology London: Wiley NIH (2013) Assisted Reproductive Technology from Eunice Kennedy Shriver National Institute of Child Health and Human Development website, url: http://www.nichd.nih.gov/health/topics/infertility/conditioninfo /Pages/art.aspx Oats J, Abraham S. (2010) Llewellyn-Jones Fundamentals of Obstetrics and Gynaecology London: Mosby