Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Infertility

Infertility - Key Features

1. When a patient consults you with concerns about difficulties becoming pregnant:
a) Take an appropriate history (e.g., ask how long they have been trying, assess menstrual history, determine coital frequency and timing) before providing reassurance or investigating further.
b) Ensure follow-up at an appropriate time (e.g., after one to two years of trying; in general, do not investigate infertility too early).

Definition:
Inability to conceive after 12 months of intercourse without contraception.

History:
Remember to interview and investigate both the male and the female.
Age? Is it primary or secondary infertility? How often are they having intercourse? How long have they been trying? Form of birth control before trying to conceive? Erectile dysfunction? Ejaculation problems? Menstrual history (menarche, regularity, length of cycle, moliminal symptoms, endometriosis?) Past medical history (Uterine surgery, Pelvic surgery, STIs, PID, previous ectopic, previous tubo-ovarian abscess?) Intrauterine DES exposure? Symptoms of PCOS? Hyperprolactinemia? Hypo or Hyperthyroidism? Family history of infertility, birth defects, or mental retardation? Social history (smoking, EtOH, drugs, occupation, exercise).

2. In patients with fertility concerns, provide advice that accurately describes the likelihood of fertility.

Epidemiology:
50% of women conceive in 3 months, 72% in 6 months and 85% in 12 months.
Male infertility 23% (other sources state closer to 50%)
Ovulatory dysfunction 18%
Tubal damage 14%
Endometriosis 9%
Coital problems 5%
Cervical factors 3%
Unexplained 28%
Likelihood of not conceiving in 12 months if couple is normally fertile is 7%

3. With older couples who have fertility concerns, refer earlier for investigation and treatment, as their likelihood of infertility is higher.

If the woman is older than 35, start investigations and referral after 6 months of trying to conceive. (SOGC 2011 Guidelines on Advanced Reproductive Age and Infertility).

4. When choosing to investigate primary or secondary infertility, ensure that both partners are assessed.

Investigations
1) Is it male infertility?

Semen analysis with respect to concentration (>48x106/mL), motility (>63%) and morphology (>12%). Should be collected after 2-7 days of abstinence, and submitted to lab within one hour of collection.

2) Is the woman ovulating?

-Regular periods with moliminal symptoms (breast tenderness, ovulatory pain, bloating) implies ovulation.

-Serum progesterone level one week before expected menses (ie: day 21 of 28 day cycle)

-Basal body temperature [T increases by .5 to 1.0 degree F (0.25 to 0.5 degrees Celsius) in luteal phase secondary to progesterone production by corpus luteum].

-Urinary testing (detects LH surge which occurs 38 hours before ovulation).

-Day 3 FSH level to test ovarian reserve (women with a reduced pool of follicles provide insufficient inhibition of FSH secretion, so FSH inappropriately rises early in cycle).

3) If she is ovulating…

Consider luteal phase defect in which the corpus luteum does not adequately produce progesterone or the progesterone has a diminished effect on the endometrium or the endometrium lacks integrin adhesion molecule.

Endometrial biopsy to determine adequacy of luteal phase hormones on the endometrium (done 10 days after ovulation).

4) If she is not ovulating…

TSH, prolactin, FSH, LH, progesterone, estradiol, free testosterone. looking for thyroid issues, hyperprolactinemia, PCOS, ovarian failure.

5) Is it her uterus?

Hysterosalpingogram to examine for uterine fibroids, polyps, synechia, or other anomalies

Hysteroscopy if hysterosalpingography demonstrates uterine concern.

5) Is it her tubes?

Hysterosalpingography to examine for obstruction as initial test (sometimes therapeutic as well as diagnostic)

Consider laparoscopy as initial test if history of PID, intrabdominal infection, endometriosis, previous surgery.

6) Is it the cervix?

Post-coital test to examine interaction between sperm and mucus. Done 1-3 days before ovulation. Sample of mucus taken 2-12 hours post-coitus to look for >5cm spinnbarkeit and >5 motile sperm/hpf. Some debate as to usefulness of this test.

WHO Classification of Anovulation
I - Hypogonadotropic hypogonadal anovulation (problem with FSH/LH therefore no ovarian response)
II - Normogonadotropic normoestrogenic anovulation (no good reason for an ovulation)
III - Hypergonadotropic hypoestrogenic anovulation (ovaries not responding)

5. In couples who are likely infertile, discuss adoption when the time is right. (Remember that adoption often takes a long time)

Treatment of Infertility

Lifestyle modifications – Gain or lose weight, smoking cessation, decrease ETOH and caffeine intake, increase frequency of coitus.

Adoption – Must find appropriate time to discuss this.

Azoospermia or Oligospermia – Donor sperm

Uterus – Surgery (leiomyomas). Surrogacy (synechia/septa or congenital anomalies). Laparoscopic cautery (endometriosis).

Cervix – Consider intrauterine implantation of sperm or IVF to bypass cervix.

Tubes – Hysterosalpingography (flush the tubes). Surgery [tubal reconstruction, adhesiolysis, salpingectomy (for hydrosalpinges that may secrete embryotoxic substance)]. Consider IVF.

Anovulation – Class II anovulation responds to treatment.

Medication - Clomiphene or other SERMs (to stimulate ovulation), Metformin +/- clomiphene (PCOS), Gonadotropins (to stimulate ovulation in non-PCOS), Dopamine (hyperprolactinemia).

Surgery – Wedge resection or drilling of ovary (PCOS).

IVF +/- oocyte donation

6. In evaluating female patients with fertility concerns and menstrual abnormalities, look for specific signs and symptoms of certain conditions (e.g., polycystic ovarian syndrome, hyperprolactinemia, thyroid disease) to direct further investigations (e.g., prolactin, thyroid-stimulating hormone, and luteal phase progesterone testing).

PCOS signs and symptoms: Amenorrhea/oligomenorrhea, obesity (often, but not always), hirsutism, acne, infertility, and bilaterally enlarged polycystic ovaries.
Family hx: 40% of sisters and 20% of mothers of affected women with PCOS also have it

Hyperprolactinemia signs and symptoms: Galactorrhea, amenorrhea. If resulting from pituitary tumour, may experience headaches, visual disturbances.

Hypothyroid signs and symptoms: fatigue, weight gain, cold intolerance, constipation, myalgia, oligomenorrhea or menorrhagia, anemia

Hyperthyroid signs and symptoms: anxiety, tremor, palpitations, weight loss, heat intolerance, increased appetite, oligomenorrhea or amenorrhea

Study Guide

Infertility

Resources

UpToDate
SOGC Guideline on Advanced Reproductive Age and Infertility 2011 (www.sogc.org/guidelines/documents/gui269CPG1111E_000.pdf)
PEPID
Previous residents “CCFP Priority Topics” document