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Infertility

Infertility is defined as the inability to conceive after two years of regular unprotected intercourse, affecting primary and secondary couples alike. While 84% conceive within a year, timely investigation is crucial, especially for women over 35 or with known issues. Initial assessments include hormone evaluations and semen analysis. Treatments vary based on factors, including medication for anovulation, surgical options for male issues, or assisted reproductive techniques like IVF. Lifestyle modifications and counseling are also essential for optimal outcomes.

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Infertility

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  1. Infertility

  2. 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.

  3. Management History • 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.

  4. Examination Female BMI Hyperandrogenism Galactorrhea Pelvic abnormalities Male Assess genitalia if history suggestive or semenalysis abnormal

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

  6. 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

  7. 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

  8. Treatment Male Factor • Hypogonadotrphic hypogonadism – gonadotrophins • Obstructive azoospermia – surgical correction • Correction of varicocele

  9. 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)

  10. Tubal Disease • Ablate endometriosis at the time of laparoscopy • Tubal surgery • IVF

  11. Intrauterine Insemination • Used in unexplained or mild male factor infertility. • Outcome may be no better than expectant management.

  12. 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

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

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