Infertility

Question 1

27yo F comes in with her 30yo husband complaining of infertility despite trying for a year. How would you investigate and manage the couple?

2020 stem: Couple have had unprotected sex for three years and have been unable to conceive. Ask questions about the couple for further history and talk about relevant investigations and management.

Answer 1

Impression
This couple fulfils the criteria for infertility, which for <35yo is 12 months of regular unprotected sex without without conception. For >35yo, 6 months is sufficient.

There are many causes of infertility to consider, and would take systematic approach to identifying and treating potential underlying causes;

Female (40%)
- Intrinsic (age)
- Anatomical: tubal, uterine
- Physiological: hypopituitarism, PCOS, ovarian insufficiency, hyperprolactinaemia
Male: (40%)
- Sperm: failed production, oligospermia, poor motility
- Anatomical: blocked vas deferens, absent (cystic fibrosis)
- Physiological: erectile dysfunction

20% is both male and female problem

Question 2

Infertility - History

Answer 2

History
- PC: how long trying for, frequency of intercourse, timing of intercourse, any contraception
Start questioning with male first.
- Male: sexual history, any sexual dysfunction (erectile dysfunction, ejaculation, PMHx of testicular trauma or
- Female: menstrual history, sexual history, obstetric history, sx of anovulation (amenorrhoea, irregular periods), sx of androgenising (PCOS)
pathology (varicocele, undescended testes etc)
- Complete the medical history (medications, SNAP)

Question 3

Infertility - Examination

Answer 3

Examination
- General appearance;

Female:
- abdominal + pelvic examination: masses, tenderness, irregularities

Male
- Testicular examination: volume, masses, abnormalities

Question 4

Infertility - Investigations

Answer 4

Investigations
There are a number of investigations to be conducted in a sequential fashion in the setting of unexplained infertility, for both male and female partners.

Female

• Confirm ovulation: day 21 (midcycle) progesterone (should rise 7-10 days post-ovulation
• cervical mucous testing (anti-sperm antibodies)
• pelvic US for anatomical abnormalities
• hysterosalpingo-contrast-sonography (HySoCo scan)
• pituitary panel, sex hormone levels
• then baseline antenatal care, pre-conception screen (rubella, measles, HIV, HepC/B, etc)
• referral to fertility clinic

Male

• Semen analysis: volume, concentration, motility, morphology, seminal fluid parameters
• sex hormones levels (LH, FSH, test, PRL
• testicular ultrasound

Question 5

Infertility - Management

Answer 5

Management
Referral to fertility clinic for further work-up/ definitive management.

Supportive:

• continue naturally, cycle monitoring, urinary LH monitoring
• ensure complete pre-conception care, eg folic acid supplements etc

Definitives for females

• ovulation induction (clomiphene PO, antagonises estrogen receptors therefore prevents negative feedback mechanism)
• intra-uterine insemination
• IVF/ICSI - would need to have counselling and referral to fertility clinic

Definitives for males

• medical therapy: testosterone, clomiphene citrate
• surgical treatment for testicular anomalies/defects