Infertility / Subfertility in the couple trying to conceive

The topic of subertility and infertility was examined in KFP 2017.2, Case 5 which had the context of PCOS in the female with a focus on that as well as thinking broadly.

Bill and Sally present to your practice concerned about their inability to conceive over the past 6 months. They have one healthy baby and nil significant past medical history.

What are the general facts?

12 months of no baby
95% will conceive in 2 years
Affects 1 in 17 couples
15% don’t conceive in 12 months
40% male problem
40% female problem
20% no cause found

What are the causes of male infertility?

Sperm autoimmunity – sperm antibodies IgG IgA
Failure of spermatogenesis –
- Hormonal axis – GnRH from hypothalamus, FSH and LH from pituitary
Failure of sperm delivery

What are the causes of female infertility?

Tubal problems 20%
PCOS most common cause
Hyopthalamus-Pituitary axis =
- GnRH, FSH, LH;
- Folliucular response to LH and FSH;
- Prolactin levels (normally low)
Receptive cercival mucus
Normal utuerus for implantation
Normal tubal transport

What are the Key Features of History in Male infertility?

Sexual function
Previous testicular problems
Previous urethral problems
PMHx
- Diabetes
- Eilepsy
- TB
- Kidney disorders
- PH of STIs
- PH Mumps
- Recent severe febrile illness
- Chemo
- Aminoglycosides
Previous genitourinary surgery
Occupational history
- exposure to pesticides, heat, herbicides
Social History
- Drug intake
- Alcohol
- Anabolic steroirds
- Nicotine

What are the key features of history in female infertility?

Onset of menarche
Symptoms of endometriosis
PH of STIs
PH of pelvic infection
Prev IUCD
PH of intra-abdominal surgery
PH of genitourinary surgery
Obstretric history
Eating disorders

What are the key features of Examination in Male Infertility?

Secondary sexual charecetritiscs
Genitalia size and considentcy
Present and non-tender epidydimus and vas deference
Absence of varicocoele
Normal prostate
Uethral presence and location

What are the key features of examination in female infertility?

Secondary sexual characteristics
Thyroid status
Genitalia and breasts
Nil masses in adnexae

What are the key investigations in male infertility?

Semen analysis – 2 samples 90 days apart
If sperm bad then
serum FSH – most improtant test
Sperm function tests
46XXY or 46XXY/46XY or microdeletion
testosterone
test ultrasound

What are the key investigations?

Temp diary
Cervical mucus diary
Midluteal hormone assessment (21st day of cycle) = low LH, high progest, hi oestridiol
Ovulation = luteal progestreone
Rubella immune status
TFT
Serum prolactin, FSH, LH, androgen
Cervical culture for chlamydia
Sonohsyterogram
Transvaginal USS
Diagnostic laparoscopy
Hysteroscopy
CT of pituitary fossa