What is infertility defined as?
The failure of contraception in a couple having regualr, unprotected coitus for one year
What % of couples will be pregnant after 12 cycles?
What are the categories of infertility?
What is primary infertility?
No previous pregnancy
What is secondary infertility?
Previous pregnancy, successful or not
What proportion of couples have difficulty conceiving?
Around 1 in 7
How many people in the UK have trouble conceiving?
What should be included in a female infertility history?
- Duration of infertility
- Information about menstrual cycle
- Tubal or pelvic surgery
- Pelvic pain
- Sexual history
What information should be obtained about the menstural cycle in an infertility history?
- Length of cycle
- Predictability of cycle
- Age of menarche
What is an important consistuent of the sexual history when taking a female infertility history?
What should be included in a male infertility history?
- General health
- Previous surgery to testes
- Drug history
- Previous infections
- Sexual dysfunction
What should be included in infertility examination?
- Signs of secondary sexual characteristics
- Pelvic examination - feel for structural abnormalities
When is a male infertility examination performed?
Do not usually perform a male examination in the absense of relevant history
What is looked for on a male infertility examination?
Testicular size and descent
What are the causes of infertility?
- Male factors
- Ovulatory disorders
- Tubal damage
- Uterine or peritoneal disease
- Other factors, including unexplained infertility
What % of infertility is due to male factors?
What male factors cause infertility?
- Idiopathic oligospermia
- Abnormal sperm production
- Hypothalamic/pituitary dysfunction
- Ductal obstruction
- Failure to deliver sperm to vagina
What may result in abnormal sperm production?
What may cause ductal obstruction?
- Post-infective epididymitis
What may result in failure to deliver sperm to the vagina?
What % of infertility is caused by ovulatory disorders?
What can ovulatory disorders be classified into?
- Group 1 - hypothalamic pituitary failure
- Group 2 - hypothalamic-pituitary-ovarian dysfunction
- Group 3 - ovarian failure
What is polycystic ovarian syndrome?
A syndrome consisting of polycystic ovaries and systemic features resulting from elevated androgens
What causes polycystic ovary syndrome?
Unknown pathophysiology, but appears to have genetic component
What does polycystic ovary syndrome result in?
- Increased androgen secretion
- Raised LH/FSH ratio
- Insulin resistance
- Multiple small ovarian cysts
What is anovulation?
Amenorrhoea or oligomenorrhoea
What are the clinical features of polycystic ovary syndrome?
- Male-pattern baldness
- Psychological symptoms
What are the psychological symptoms of polycystic ovary syndrome?
- Mood swings
What is the Rotterdam Diagnostic Criteria for polycystic ovary syndrome?
- Polycystic ovaries (12 or more follicles on ultrasound
- Oligo-ovulation or anovulation
- Clinical and/or biochemical signs of hyperandrogenism
- Exclusion of other causes of androgen excess
What % of infertility is due to tubal damage?
What is tubal damage caused by?
- Past pelvic infection
- Previous pregnancies
- Pelvic surgery
- Mullerian developmental anomaly
What pelvic infection can cause tubal damage?
What % of infertility is due to uterine or peritoneal disease?
What uterine or peritoneal diseases can cause infertility?
- Asherman's syndrome
- Uterine fibroids
- Cervical stenosis
- Cervical hostility
What is endometriosis?
Presence of endometrial tissue in sites other than the uterine cavity
Where is endometriosis most common?
In the pelvic cavity
What are the clinical features of endometriosis?
- Chronic pelvic pain
What is cervical hostility due to?
Infection or female sperm antibodies
What other factors can cause infertility?
- Poorly controlled diabetes
- Coital problems
In what % of cases is infertility multifactoral?
When should a women be referred for investigation into infertility?
- When she is of reproductive age and has not conceived after 1 year of unprotected vaginal sexual intercourse, in the absence of any known cause of infertility
- When she is of reproductive age, and is using artifical insemination to conceive (with either partner or donor sperm), who has not conceived after 6 cycles of treatment, in the absence of any known cause of infertility
Who should recieve early infertility referral?
- Women >36 years
- Known clinical cause of infertility, or a history of predisposing factors for infertility
What investigations should be done in a female with infertility?
- Follicular phase LH, FSH (day 2)
- Luteal phase progesterone (day 21) if ovulating regularly
- Prolactin, androgens, TFTs
- Cervical smear
- Pelvic USS
- Tests of tubal patency
What investigations should be done in a male with infertility?
- Sperm analysis
- Antisperm antibodies
- Cystic fibrosis
- Testicular biopsy
What are normal semen analysis results?
- Volume >2ml
- pH 7.2 – 7.8
- Sperm count >20 million per ml
- Motility >50%
- Morphology >50% normal
What does management of infertility depend on?
How is ovulation induced?
- Clomifene citrate
- GnRH agonists
- Weight loss/weight gain
- Dopamine agonists
- Ovum donation
How is tubal occlusion treated?
- Tubal surgery (re-anastomosis)
- Assisted conception
How are male factors treated in infertility?