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INFERTILITY
Defined – as failure to conceive after 1 year of regular unprotected intercourse.
= 10-15% of couples of reproductive age ie 15-44 years old (not nec no children, just
not amount they want).
Causes
EGG
1. Ovulatory Problems – 10-25%
SPERM
2. Spermy dysfunction, male factor – 30-40%
EGG AND SPERM MEETING
3. Pelvic facrtors (tubal disease or endometriosis) – 30-50%
4. Cervical factors – 5-10%
5. Sexual factors – 5%
UNEXPLAINED
6. Unexplained – 20%
ASSESSMENT
HISTORY:
 Introduce yourself
 Purpose of inetrview
 Age
 Length of time attempting to conceive: if <2 yrs = NO conception delay
 Frequency of intercourse. When during cycle? Be specific.
 His of previous pregnancies
 Any children from prev relationships
 LMP and menstrual history
 Gynae his – esp STIs, fibroids, endometriosis, any Sx eg oophorectomy,
sterilisation (don’t miss the obvious)
 Past and present health of husband, childhd illnesses – mumps orchitis, any sx
as child (eg maldescent of testis)
 Occupations of couple – both and home circumstances
 Smoking and alcohol -both
Female
Cycle: length – normal = 21-35d. BUT within an individual NOT more than 4d
variation.
History of pelvic infection or abdominal surgery (suggests tubal abnormality, but 50%
of BTO have no clinical history of pelvic infection or Sx)
Male
History of mumps
Sx as a child – ie suggestive of mal descended testes
ETOH, Smoking, recreational drugs – these affect sperm number and are reversible
SPECIFIC ASSESSMENT – Go through each cause
Woman
Ovulatory Dysfunction
- Differentiate between primary and secondary infertility
Primary – a woman has never been pregnant despite more than 1 year
of unprotected intercourse.
Secondary – history of proven pregnancy (liveborn, ectopic, TOP) yet
is currently unable to conceive after 1 year of unprotected intercourse)
Evidence of ovulation from history
- Menses at regular monthly intervals
- Mittelschmerz – localised lower quadrant discomfort during ovulation
- Moliminimal symptoms (breast tenderness and pelvic discomfort)
- Mild dysmenorrhea
Investigations
- Rubella
- Sickle status if appropriate
- FBC
- High vaginal swabs – incl Chlamydia, if +ve = chance of tubal disease,
therefore do laproscopy earlier.
- Early mid-follicular phase FSH: NORM = <10. if >10 = suggests less
ovarian reserve (number of eggs left in ovary)
- To confirm ovulation: progesterone level 7-10d before next period =
mid-luteal phase progesterone and >30mmol/L confirms ovulation.
- Cyclical Monitoring
Gives info for patients, access ovarian morphology, endometrial response, access
endometrium – need an endometrium of .8mm to increase chance of implantation at
time of oulation; can see if follicle growing (1 inch) and can time progesterone
measurement.
- Once confirmed ovulating
-assess tubal function and integrity of cavity.
1) laproscopy – Gold standard. Fully asses pelvis – to diagnose endometriosis and
adhesion formation. But involves GA. Longer trying to conceive = more likely to do
laprosocpy.
2) Hysterosalpingogram = xray of womb with dye. Dye tells you about cavity of
womb and inside of tubes, if mucosal folds are maintained. And if dye spills out the
end = patent tubes. Wont tell you about adhesions.
Male
Investigations
Sperm test
Separation Test
Male problems can cause infertility
It used to be that infertility was considered a "woman's problem." The truth is that of
the 80 percent of couples with a diagnosed cause, about half are the result of male
problems.
What are some causes of male infertility?
 No sperm production
 Too little sperm production
 Lifestyle factors, including: use of alcohol, marijuana, nicotine and certain
medications
 Environmental toxins, pesticides and lead
 Mumps, sexually transmitted diseases, leading to impaired function of the
testicles.
 Inability to ejaculate normally because of diabetes, surgery of the prostate
gland or urethra, blood pressure medication or other medications, or
impotence
A man's fertility workup will focus on the number and health of his sperm. The
laboratory will look at a sperm sample to check for sperm number, shape and
movement.
Cases
Case 1 – Pregnancy - General
You are a GP, a couple come into your practice who thinking of getting pregnant, and
have been trying for 4 months, they come to for general advice, and are particulary
concerned as dad is 65 and mum is 34. They want to understand how conception
occurs, and are looking for general advice on getting pregnant.
Couple: What are our chances of becoming pregnant?
For normal couples, the chance of conception per cycle attempted is about 0.2 or 20%
in normally fertile couples.
Is fertility related to age?
Yes, most certainly in women, much less so in men. Infertility rates of 10% in
women under 30, 15% in women 30-35, 30% in women 35-40, and 60% in women
over 40.
What can we do to increase our changes?
General Advice
“It takes some people longer to conceive than others. In the event of an infertility
problem, many setbacks can be identified and treated. In recent years, there have been
major advances in medical treatment that have helped people conceive a child.
It takes most couples about six months of having regular sex for conception to occur.
The odds are about 20 percent that conception will occur during each menstrual cycle,
ie in between every period you have.
But this can vary depending on age, overall health, and frequency of sex. If you
haven't conceived after 12 months of regular sex, come back and see your GP. Many
people, who have been trying for a year, go on to conceive later without problems.
(If you are older than age 35, you should talk to your Dr after trying for six months.)
You aren't alone - The statistics for infertility are higher than you might think. One
in every six couples has some kind of fertility problem.”
(Patient Education-A couple needs to know the basics of human reproduction, the
chances of becoming pregnant, when best to have intercourse, common causes of
infertility, investigative tests available, cost and discomfort associated with tests, and
therapies available with expected success rates.)
The couple want to know how conception actually occurs?
Ovulation and fertilization are the keys to conception. Ovulation is the release of an
egg from an ovary. Ovulation usually occurs about 14 days after the first day of the
last menstrual period. Once an egg is released, it can be fertilized in 12 to 24 hours.
Sperm from a man's semen travels up into the fallopian tubes where it can live for
three days or longer. If the sperm and the egg join together, fertilization occurs. The
fertilized egg then moves through the fallopian tubes into the uterus, where it attaches
and begins to grow throughout pregnancy.
Infertility can be caused by a problem anywhere along this chain of events.
Sometimes infertility has more than one cause.
If we are unable to get pregnant, what might be the cause of this?
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To patient: Imagine conception as a relay race involving parallel events by
both the egg and sperm. If conditions are just right, the sperm can make its
way to the fallopian tubes. There, if an egg is waiting, it will join it and be
fertilized. Then the egg must move through the tubes into the uterus where it
must attach to the uterine wall if conception is to be successful.
A problem at any point in this process can stop conception. The fallopian
tubes could be blocked. The semen may contain no sperm. If ovulation doesn't
happen, there will be no egg. It may take your fertility specialist the course of
a few menstrual cycles to complete an infertility evaluation.
How do I know If I’m Pregnant?
Once conception occurs, the changes that take place in your body and in the embryo
are very rapid. The placenta begins to develop and the umbilical cord forms. The heart
begins to beat. Even bones start to grow in the first 13 weeks of pregnancy. There are
signs of major changes in your body:
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Your period stops or becomes lighter
Your breasts enlarge and become more tender and may tingle
Your nipples may protrude
You may need to urinate more often
You may feel nauseous; you may even vomit
You may crave particular foods, lose your appetite or find yourself avoiding
certain foods
You may have indigestion or heartburn
You may gain or lose some weight
You may be constipated
“What pregnancy tests are there and how do I use them?”
To patient: Because of advances in home testing, you may detect pregnancy as early
as the first day of a missed period. Right after you conceive, the placenta produces a
hormone that is released into your urine and blood. Pregnancy tests can detect this
hormone.
These home tests are easy to use, accurate, and you can buy them without a
prescription. Usually, you will need to urinate on a stick that is chemically treated or
dip the stick in your urine. If the hormone is present, you'll see a sign in the test
window, usually a plus sign, blue line, or pink dot, depending on the brand of the test.
To have a better chance of getting a correct result, you must follow the directions
carefully. Taking some medications or taking the test too early usually results in a
false negative. In other words, the test indicates that you are not pregnant when you
might be.
If the test is negative but your period doesn't begin or you have other symptoms, see
your doctor or midwife. Likewise, see your health care provider if the test is positive.
The sooner you begin prenatal care, the better for you and your baby.
Case 2 – Infertility - PCOS
A 23 year old Tamil female has been trying to get pregnant for the last 3 years,
she comes in with her partner. They have been having regular intercourse. She
has a strong history of oligomenorhea.
Notes to Patient – periods started age 14, very irregular, sometimes monthly, then
every 3-4 months, sometimes up to 6/7 months. You have been having sex twice a day,
7 days a week for the last 4 years. You have acne, and facial hair has been a
nuicance. Polycystic ovaries sounds familiar, you think your aunt may have had it,
you are very curious to know what exactly it is and how you can get pregnant?Your
aunt was told she had the syndrome but not the ovaries – what does that mean?
Dad – 46 year old male, smoker and drinks a pint a night. Asks what can I do? What
are chances of having a baby?
Consultation
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Your menstrual history: When did you start your period? How often do you
have your period and how long is it? Do you experience irregular periods? Are
your periods heavy?
Your reproductive history: Have you ever been pregnant? Have you suffered a
miscarriage or had an abortion? Do you currently use or have you have use
birth control? What kind?
Your family history: Has anyone in your family ever been diagnosed with a
reproductive problem or infertility? Does anyone else in your family suffer
from PCOS?
Elicit other symptoms of PCOS
Miscarriage - There may be an increased risk of miscarriage for women who do
become pregnant.
Unwanted body hair - Many women with PCOS experience unwanted hair on their
face, chest, abdomen, arms and legs. Hair growth might be quite thick and noticeable,
especially if you have dark hair. Some women also notice a slight thinning of their
head hair.
Acne - Some women with PCOS have spots on their face, chest and back. Many
women who go to their doctor with adult acne find they have polycystic ovaries.
Weight gain - woman put on weight easily. Also leads to increased risk of
developing heart disease, high blood pressure or diabetes later in life.
Pelvic discomfort - Some women with PCOS feel occasional discomfort in their
abdomen.
Patient thinks her grandma may have had PCOS, and wants to know what it is?
Polycystic simply means 'many cysts' and describes the appearance of the ovary on
ultrasound scan. On the scan a polycystic ovary is larger than normal with a ring of
many cysts around the edge. The cysts are follicles, some are immature but contain an
egg, and others are empty. A polycystic ovary contains at least ten cysts just below
the surface, and although each cyst only measures between two and eight millimetres,
together they make the ovary enlarged. The covering of the ovary (the capsule)
thickens, which makes release of the egg difficult.
(Normal ovary showns a growing follicle and the empty follicle (called the corpus
luteum) that is left behind after the release of the egg at ovulation. Polycystic ovary many cysts around the edge of the ovary.)
Polycystic ovaries are common. About one in five women have them, and generally
they present no problems. But when they are accompanied by some, or all, of the
symptoms described below, you may be told that you have Polycystic Ovary
Syndrome (PCOS). (PCOS is sometimes called Stein-Leventhal syndrome after the
doctors who first described it in 1935.)
Symptoms of PCOS can include acne and hirsutism as well as irregular or heavy
periods.
Examiner – what investigations would you do to confirm diagnosis?
Investigations
Blood Tests
 androgens, such as testosterone.
 characteristic rise in leutenising hormone (LH).
 A progesterone blood test 7 days before your expected menstrual period can
check if you are ovulating.
 Prolactin levels may also be checked
 Since polycystic ovarian syndrome is so heavily associated with insulin
resistance, you can also have blood tested for fasting glucose and insulin
levels. In some cases, though, blood tests may show that your glucose levels
are normal, in which case you may be asked to do an oral glucose tolerance
test (OGTT) to double check that everything is actually fine. This test is useful
in identifying underlying insulin resistance issues even when a glucose fasting
test has come back normal.
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cholesterol levels may also be assessed. Women with PCOS often have high
LDL cholesterol levels, ("bad" type) of cholesterol.
Ultrasound Findings
Vaginal - giving the best views of the ovaries and pelvic organs. In PCOS, the ovaries
are found to have multiple, small cysts around the edge of the ovary. These cysts are
only a few millimetres in size, do not in themselves cause problems and are partially
developed eggs that were not released. Women with polycystic ovaries, though, may
have ovaries that are between one and half to three times large than cyst-free ovaries.
(NB just because you have cysts on your ovaries, does not necessarily mean you have
PCOS. It is actually extremely common for women to have cysts on their ovaries.
However, in PCOS, the number of cysts can be quite high, which is why these women
experience reproductive problems. Despite this, not all women with PCOS will be
found to have cysts on their ovaries. This is why a diagnosis will be based on all the
symptoms that present themselves: hormonal imbalances, evidence of insulin
resistance, skin problems, fertility issues, menstrual irregularities and ovarian cysts.)
Treatment Available
One way of regulating menstruation is by losing weight, something which can be
difficult for women with PCOS.
Treating irregular or absent periods
Since follicles don't ripen with PCOS, the corpus luteum doesn't form and
progesterone isn't produced. As a result the endometrium (the lining of the uterus)
does not thicken. It is the thickened endometrium which is lost with a normal
menstrual period. Many women feel better for having a period each month. If a
woman doesn't want to get pregnant, the usual way to manage PCOS is either a low
dose combined contraceptive pill, or a progestogen only pill.
Treating infertility
Of the causes of infertility, Rx of ovulation disorders is successful in as many as 8090% of cases (for other causes close to 30%).
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Drugs
Clomiphene citrate is the most commonly used ovulation-inducing drug. It is
a weak anti-estrogen that works at the hypothalamic level to intiate the
changes needed to produce an ovulatory cycle. Complications and side effects
include hot flushes, mood swings, multiple pregnancy (5% twins), ovarian
cysts, and rarely visual disturbances.
Gonadotrophins
Metformin
Laparascopic ovarian diathermy
Treatment concerning miscarriage
Miscarriage associated with PCOS is thought to be due to high levels of LH. Drugs
such as Buserelin may be used as injections or nasal sprays to suppress LH before
using other drugs to induce ovulation.
(Treatment for other symptoms…
Treatments for unwanted body hair - Unwanted hair growth (hirsutism) is caused
by excess male hormones (androgens). Polycystic ovaries produce excess amounts of
an androgen (testosterone). Although all women have some testosterone, people think
of it as a male hormone because it influences male characteristics such as body hair
and balding. For women who don't want to conceive, excess hair is usually treated
with the combined contraceptive pill and an anti-androgen. may take several months
to take effect. control hair growth with treatments such as waxing, electrolysis or
lasers, or use bleaching and foundation creams to disguise growth.
Treatment for acne Like hair growth, acne is caused by high levels of androgens and
may be helped by similar treatments. The combined contraceptive pill can help with
acne as well as regulating cycle. The progestogen-only pill can make acne worse.
Over the counter or prescribed spot treatments might be worth trying, but they dry the
skin. Antibiotics, while useful in treating some forms of acne, are not going to solve
the problem when it is hormonal.
Weight gainThe metabolism of a woman with PCOS is thought to differ from that of
a woman without it. Women with PCOS use energy from food more efficiently, so
relatively more is stored as fat. Advice to eat healthily and get plenty of exercise can
be very frustrating for women with PCOS because it is more difficult to lose weight if
you have PCOS. Advice: Try five smaller meals each day to help regulate blood sugar
levels and reduce cravings for sweet or high fat foods. Loss of between 5 and 10% of
body weight leads to a significant loss of symptoms.)
Patient wants to know what is the Difference Between PCO and PCOS?
The term 'polycystic ovaries' describes the ovaries, as seen on the ultrasound scan
above. Many women have ovaries that are polycystic, but do not have any of the other
symptoms or hormone findings as described previously.
Overall, around 20% of women of the general population have ovaries with this
appearance, and what isn't known yet from current research is whether this is one end
of a long scale including the full polycystic ovary syndrome or a sign that symptoms
are more likely to develop in the future.