1. Management of Infertility in a District General Hospital Dr. H Muppala MBBS DGO Department of Obstetrics and Gynaecology Burnley general Hospital December 2005 Burnley

2. Definitions  Infertility should be defined as ‘failure to conceive after regular unprotected sexual intercourse for two years in the absence of known reproductive pathology’

3. Definitions  The duration of the failure to conceive should be twelve or more months before an investigation is undertaken unless medical history and physical findings dictate earlier evaluation and treatment.  Primary Infertility: no previous pregnancies have occurred Secondary Infertility: a prior pregnancy has occurred

4. Statistics  84% of couples conceive within 12m, 92% will do so in 24m.  Fertility decreases with age and more so after 35 years.  Origin:  Female factor ~ 40%  Male factor ~ 30%  Combined ~ 30%

5. Etiologies  Sperm disorders 30%  Anovulation / oligoovulation 30%  Tubal disease 16%  Unexplained, Cervical factors, and other factors account for 24%

6. Etiological Factors  Pelvic inflammatory disease  Endometriosis  Spermatic varicocoele ?  Primary ovarian failure  Previous tubal/abdominal surgery  Cervical and uterine abnormalities  Fibroids ?

7. History taking  Both partners should be present  Most important part of infertility evaluation  Fertility history: duration of infertility  Obstetric history: number and outcome of previous pregnancies, postpartum or miscarriage complications  Menstrual history: age at menarche, regularity, duration and amount of bleeding, abnormal bleeding.

8. History taking  Contraceptive history.  History of medical illnesses.  Family history of genetic diseases.  Personal history: smoking, alcohol, drug abuse.  Sexual history: knowledge, frequency, dysparenuia, vaginismus.  Gynaecological history: PID, STI.  History suggestive of ovulatory disorders: exercise, cyclical pelvic pains, hot flushes, hirsutism, galactorrhoea, stress, eating disorders, stress, eating disorders.

9. History taking in Male partner  Sexually transmitted infections  Testicular surgery/injury  History of Mumps  Radiation, cytotoxic drugs usage, exposure to toxic substances  Excessive heat exposure

10. Initial Advice  Natural conception  Frequency and Timing of sexual intercourse  Alcohol consumption  Smoking  Caffeinated beverages  Tight underwear for men  Body weight  Occupation

11. Initial Advice  Prescribed, over-the-counter and recreational drug use  Complementary therapy  Folic acid supplementation  Susceptibility to rubella  Cervical cancer screening

12. Assessment and Referral  Failure to conceive at 1yr  History of predisposing factors  Known reason for infertility  Chronic viral infections

13. Principles of care  Disease of couples, not individuals  Emotional and Educational Needs  Feelings of guilt, frustration and anger  Support groups and counseling

14. Investigation of fertility problems and management strategies

15. Semen Analysis  Volume: 2.0 ml or more  Liquefaction time: within 60 minutes  pH: 7.2 or more  Sperm concentration: 20 million spermatozoa per ml or more  Total sperm number: 40 million spermatozoa per ejaculate or more

16.  Motility: 50% or more motile, or 25% or more with progressive motility within 60 minutes of ejaculate  Vitality: 75% or more live  White blood cells: fewer than 1 million / ml  Morphology: 15% or 30%  Screening for anti-sperm antibodies  Repeat confirmatory tests

17. Physical Exam-Female  Pelvic masses  Uterosacral nodularity  Abdominopelvic tenderness  Uterine enlargement  Uterine mobility  Cervical abnormalities  Thyroid exam

18. Assessing Ovulation  Menstrual history  Regular menstrual cycles + 1yr infertility  Irregular menstrual cycles  BBT not recommended  FSH, LH, Prolactin, Inhibin B, TSH  Endometrial biopsy

19. Screening for Chlamydia trachomatis  Before uterine instrumentation  Appropriate management  Prophylactic antibiotics

20. Assessing Tubal Damage  Women with out co-morbidities should be offered HSG  Hysterosalphingo-contrast ultrasonography  Laparoscopy and dye The results of semen analysis and assessment of ovulation should be known before a test for tubal patency is performed.

21.  Assessing uterine abnormalities  Post-coital testing of cervical mucus

22. Physical Exam-Male  Testicular descent and its size  Presence of varicocoele  Urinary tract abnormalities  Signs of STI

23. Medical and surgical management of male factor fertility problems  Men with hypogonadotrophic hypogonadism should be offered gonadotrophin drugs  Idiopathic semen abnormalities  Men with antisperm antibodies  Men with leucocytes in their semen  Obstructive azoospermia, Varicocoele  Ejaculatory failure

24. Classification of Ovulatory Disorders  Group Ι: Hypothalamic pituitary failure  Group Ι Ι: Hypothalamic pituitary dysfunction (e.g. PCOS)  Group Ι Ι Ι: Ovarian failure

25. Ovulation Induction  Anti-estrogens for Group Ι Ι ovulation disorders (clomifene citrate or tamoxifen)  Risk of multiple pregnancy  Chance of pregnancy increases with unexplained infertility  Ultrasound monitoring for the first cycle

26. Metformin & Ovarian Drilling Metformin is not currently licensed for the treatment of ovulatory disorders in the UK.  Anovulatory women with PCOS, who have not responded to CC and with BMI >25 should be offered Metf combined with CC  Women with PCOS who have not responded to CC should be offered with Laparoscopic Ovarian Drilling

27. Gonadotrophins  PCOS women who failed to ovulate with CC or Tamoxifen should be offered GT  PCOS women who ovulate but failed to become pregnant in 6m should be offered CC stimulated IUI  PCOS women should not be offered concomitant GT and GT-RH agonists

28. Pulsatile GT-RH & Dopamine agonists  Women with Group Ι ovulatory disorders should be offered pulsatile GT-RH or GT with luteinising hormone activity  Pulsatile GT-RH in CC resistant PCOS women is not recommended  Women with ovulatory disorders due to hyperprolactinaemia should be offered bromocriptine

29. Monitoring Ovulation Induction  Risk of multiple pregnancy and ovarian hyperstimulation  Ovarian ultrasound monitoring

30. Other risks and side effects associated with ovulation induction agents  Risk of ovarian cancer uncertain  Lowest effective dose and duration of use

31. Tubal and Uterine Surgery  Tubal microsurgery and laparoscopic tubal surgery  Tubal catheterisation or cannulation  Hysteroscopic adhesiolysis

32. Medical & Surgical management of Endometriosis  Medical treatment of minimal & mild E is not recommended  Women with minimal or mild E who undergo laparoscopy, E ablation or resection with adhesiolysis should be offered  Ovarian endometriomas-lap cystectomy  Surgery should be offered to women with moderate or severe E

33. The Endless End