Infertility

Overview

Infertility is the inability of a couple to conceive with regular intercourse (3-4 times per week) and in the absence of contraception after 12 months in women < 35 years and 6 months in women > 35 years. Infertility is not recurrent pregnancy loss. Most couples will achieve pregnancy within 6 months. The rate of conception goes down the longer it takes for the couple to conceive. The goal of treatment is to counteract or correct underlying factors that may contribute to infertility

Primary infertility: The couple meets the definition of infertility and has never been able to conceive. Prevalence increases with the age of the female partner. ****

Secondary infertility: The couple meets the definition of infertility but has conceived before

Fecundability: the probability of achieving pregnancy in one cycle. Around 0.20-0.25. Lowers with increasing age of the female partner.

Causes of infertility in women

Causes of primary hypogonadism in men

Causes of secondary hypogonadism in men

Evaluation of Infertility

• Questions on conception
  • Has the couple been able to conceive before?
  • Has either member of the couple conceived before (with another partner)?
• Menstrual history
  • Has she ever had a period? (rule out primary amenorrhoea)
  • Does she have regular periods?
  • How long are her cycles?
  • Does she have symptoms with her periods/ (e.g. cramping, bloating)
  • Are her periods painful? (dysmenorrhea = endometriosis)
• Sexual history
  • When and how often is the couple having sex?
  • Is it painful?
  • What is his libido? (Low libido = androgen insensitivity)
  • When did each start puberty? (Should be at tanner stage V)
  • History of STDs or genitourinary infections (PID)
• Past medical history
  • Weight (extremes of BMI)
  • Chronic illnesses
  • Medications
• Past surgical history
  • History of gynaecologic surgery (e.g. oophorectomy, dilation and curretage causing Asherman syndrome)
  • Has he had any genitourinary or inguinal surgery? (Vasectomy, Orchidectomy Herniorrhaphy)
• Social history
  • Alcohol
  • Drugs (including anabolic steroids)
  • Stress
• Physical exam of the female partner
  • General exam: Abnormal body habitus, lack of secondary sex characteristics (breast, hair distribution)
  • Skin: Hirsutism, acne (PCOS)
  • HEENT: abnormalities of the thyroid gland, male pattern balding (PCOS)
  • Breast: underdeveloped, expressable milk from nipples
  • Abdomen: abdominal striae, truncal obesity
  • Pelvic exam
    • External: lack of pubic hair
    • Vaginal/cervical: lack of patent cervix, double cervix
    • Uterine/adenxal: Structural (Mullerian) abnormalities, leiomyomas, retroversion, tender nodules
• Physical exam of the male partner
  • General exam: Eunuchoidal habitus (long arms and legs; upper/lower body ratio < 1); obesity and decreased muscle mass
  • Skin: absence or loss of axillary; facial hair
  • Breast: Gynecomastia
  • Pelvic
    • Inguinal: Direct inguinal hernia
    • External/phallus: absence or loss of pubic hair; abnormally small phallus
    • Scrotal/testicular: undescended or absent testicle; absence of vas deferens; epididymal thickening or cyst; varicocele; indirect inguinal hernia

Management of Infertility

• Investigations
  • Semen analysis: always get a semen analysis
  • Assess ovulatory function: Mid-luteal progesterone level or OTC urinary ovulation prediction kit
    • Abnormal mid-luteal progesterone levels = amenorrhoea
      • Serum prolactin
      • FSH
      • TSH
      • Assessment of PCOS (ultrasound)
  • Assessment of ovarian reserve: Day 3 FSH and estradiol levels should have ≤ 10 mIU/L)
    • Abnormal levels suggest menopause or premature ovarian failure
  • Hysterosalpingogram (HSG): evaluate the anatomy of the uterus and fallopian tube using a die. Performed as part of the initial workup or postponed until normal semen analysis and ovulation are confirmed
    • Tubal damage → Laparoscopy to further assess and attempt Tuboplasty
• Treatment if semen analysis is abnormal
  • Assisted Reproductive Technology (ART)
    • Intrauterine insemination (IUI) – mild to moderate decreased density
    • Intracytoplasmic sperm injection followed by in viro fertilization (ICSI + IVF) – severe abnormalities
    • Artificial insemination with donor sperm (AID) – absence of viable sperm
• Treatment if the cause is the cause is anovulation
  • Correct underlying cause (Hypothyroidism, hyperprolactinemia, PCOS)
  • Clomiphene citrate to induce ovulation – idiopathic or due to menopause/ovarian dysfunction
  • Human menopausal gonadotropin – second line agent if Clomiphene fails
• Treatment if there is tubal damage
  • Tuboplasty
  • IVF

Semen Analysis parameters