Subfertility

Fertility declines with age

Couples seen together
Stress should be reduced
Stress in one partner can affect the other
Reduce Libido
Reduce frequency of intercourse
Contact fertility groups
Counselling
Before, during and after treatment
Provided by someone not directly involved in treatment

CHANCE OF CONCEPTION
Natural conception
85% couples will conceive within 1 year if
Women <40 years
Have regular sex
Do not use contraception
50% of those who do not conceive within the first year, will do so in the 2nd year
Cumulative pregnancy rate of 93% in 2 years.

Intrauterine insemination
Timed around ovulation
50% of women under 40 years, will conceive within 6 cycles of IUI
50% of those who do not conceive within 6 cycles, will do so with a further 6 cycles
Cumulative pregnancy rate of 75% with 12 cycles.
Greater conception rates with
Fresh sperm
Intrauterine insemination

Sexual intercourse
Every 2-3 days
3 times per week
Fertile period
6 days preceding and including day of ovulation
Alcohol
Females 1-2 units once/twice a week
Avoid episodes of intoxication
Males 3-4 units/day
Avoid excessive alcohol
Detrimental to sperm
Smoking
Cessation of smoking warranted
Fertility affected by active/passive smoking
Caffeine
No evidence to support causation
Obesity
BMI >30kg/m2 Longer time to conceive
Losing weight increases chance of ovulation
Low bodyweight
BMI <19kg/m2 Irregular menstruation likely
Tight underwear
Occupational hazards
Medications that affect fertility
Complementary therapy
Supplementation
Folic acid 400µg/day

NOTE – Further assessment

After regular unprotected intercourse with the same partner for >1 year
After 6 cycles of IUI, in the absence of any known cause of infertility

NOTE – Earlier referral

Women >36 years
Known clinical cause for infertility
Male factor
Female factor
History of predisposing factors

INVESTIGATIONS
SFA
Volume ≥1.5ml
pH ≥7.2
Concentration ≥15milliom/ml
Total ≥39million
Motility
Total 40%
Progressive 32%
Vitality 58%
Morphology ≥4%

NOTE – abnormal SFA

If first test abnormal
Repeat confirmatory test
If gross spermatozoa deficiency (azoospermia, gross oligozoospermia)
Repeat test as soon as possible

Anti-sperm antibodies
No evidence to improve treatment
Not offered
Postcoital testing of cervical mucus
No predictive value
Not routinely offered
Ovarian reserve
Recommended
Woman’s age
Antral follicle count 4-16 follicles/ovary
 AMH 5.4-25pmol/l
FSH 8.9-4iu/l
Not recommended
Ovarian blood flow
Inhibin B
Oestradiol
Ovarian volume
Ovulation tests
Regular cycles Day 21/mid luteal phase progesterone
Irregular cycles 7 days before menstruation
Repeated weekly
Until next menstruation starts
Basal body temperature method
Not recommended
Does not predict ovulation reliably
Irregular cycles
Measure serum gonadotrophins (follicular phase)
Prolactin
Only offered if symptoms present
Ovulatory disorder
Galactorrhoea
Pituitary tumour
Thyroid function test
Initially a TSH
If TSH >2.5mU/l
Repeat TSH
Test for thyroid antithyroglobulin antibodies
If TSH >4.5mU/l
Check T3, T4 and thyroid antithyroglobulin antibodies
Maintain TSH <2.5mU/l
Endometrial biopsy
No evidence
Investigations for Tubal and uterine anomalies
HSG Not known to have comorbidities
PID
Previous ectopic pregnancy
Endometriosis
Less invasive
HySyCo is an effective alternative
Lap & dye Known to have comorbidities
Simultaneously to assess and treat other pelvic pathology
Investigations for uterine anomalies
Hysteroscopy
Not routinely offered
Unless clinically indicated
Viral status
IVF Test for HIV, hep B and C
NOTE – HIV transmission
Negligible if
Man is compliment on highly active anti-retroviral therapy
Viral load <50copies/ml for more than 6 months
No other infections present
Unprotected intercourse is limited to time of ovulation

NOTE – Sperm washing

Reduces risk of HIV
Does not eliminate risk
Reduces likelihood of pregnancy
Offered when
Man not compliant
Viral load >50copies/ml

Screening for chlamydia

Indicated prior to uterine instrumentation
If positive Treat woman and sexual partners
Prophylactic antibiotics should be considered if screening not carried out

MALE FACTOR PROBLEMS

Hypogonadotropic hypogonadism Gonadotrophins
Leucocytes in semen
Semen culture
Antibiotics if infection present
Obstructive azoospermia Surgical correction
Varicocoele surgery
Not recommended
Does not improve pregnancy rates
Ejaculatory dysfunction Medical management

OVULATORY DYSFUNCTION
*Refer note on Anovulatory infertility
WHO 3 types
Type 1 Hypothalamic pituitary failure
Hypothalamic amenorrhoea
Hypogonadotropic hypogonadism
Type 2 Hypothalamic pituitary ovarian dysfunction
Type 3 Ovarian failure/insufficiency

Management
Type 1 Type 2 Type 3
Increase BMI if <19kg/m2 Weight reduction if BMI >30kg/m2 Donor egg
Moderate exercise Ovulation inductiona
Pulsatile GnRH Follicular tracking
FSH/LH
Dopamine agonists
(hyperprolactinaemia)
a
Clomiphene citrate or metformin or combination of both

Clomiphene citrate treatment for 6 months only

Metformin side effects
Nausea
Vomiting
Gastrointestinal side effects
If resistant to clomiphene/ovulation induction
Laparoscopic ovarian drilling
Combination of clomiphene and metformin
If not offered as first line
Gonadotrophins

NOTE – PCOS and gonadotropins

Do not offer GnRH agonists concomitantly
Does not improve pregnancy rates
Risk of OHSS

TUBAL SURGERY
Beneficial with mild tubal disease
Proximal tubal disease
Selective salpingography
Tubal catheterization
Hysteroscopic tubal cannulation

NOTE – Hydrosalpinges
Offer salpingectomy prior to IVF
Improves chance of live birth

UTERINE SURGERY
Amenorrhoea due to uterine adhesions
Hysteroscopic adhesiolysis
Restores menstruation
Improves implantation

UNEXPLAINED INFERTILITY
DO not offer ovarian stimulation agents
Offer regular unprotected intercourse for 2 years
Can include 1 year before fertility investigations
Depending on age
Offer IUI
Offer IVF treatment thereafter

<35 years 35-39 years >39 years

Expectant
2 years 1 year Not offered
management
IUI cycles with FSH 3-6 2-3 2
INTRAUTERINE INSEMINATION
Consider 6 cycles of unstimulated IUI in
Difficult to have vaginal intercourse
Physical disability
Psychosexual problem
Specific considerations
Sperm washings when man HIV positive
Same sex relationships with donor sperms
Consider 6 cycles of stimulated IUI later

NOTE – Routine IUI

Do not offer if
Mild endometriosis
Mild male factor infertility
Advise to conceive for 2 years

NOTE – Donor insemination

Indications
Obstructive azoospermia
Non-obstructive azoospermia
Severe deficits in semen quality
Risk of transmitting genetic disorder
Risk of transmitting infectious disease
Severe rhesus isoimmunization

NOTE – Oocyte donation

Indications
Premature ovarian failure
Gonadal dysgenesis (Turner syndrome)
Bilateral oophorectomy
Ovarian failure following chemoradiotherapy
High risk of transmitting genetic disorder
IVF treatment failure

FERTILITY PRESERVATION
Cryopreservation of sperm and eggs
Prior to chemoradiotherapy