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Investigation of infertility

  • 80% couples conceive after 12 months, 90% after 18 months

  • Causes

    • anovulation -21%

    • male factor - 24%

      • obstructive azoospermia

      • testicular failure

      • congenital abnormalities

      • sexual factors

      • varicocele

      • endocrine disturbances

    • unexplained -27%

    • tubal factors - 14%

    • endometriosis - 6%

    • sexual dysfunction - 6%

    • mucus hostility - 3%

      • ?immunological - <5% male factor cases

Initial consultation

  • age - 50% over 40s infertile

  • duration of infertility

  • previous fertility with other partners

Male

History

  • episodes of testicular pain / swelling

  • infection

    • TB, orchitis, epiydimitis

  • trauma

  • testicular or groin injury

  • underwear

  • tobacco, alcohol, cannabis

  • chemotherapy

  • orgasm problems

Examination

  • abdominal

  • external genitalia

  • hypospadias

  • testicular size

  • vas deferens

  • inguinal hernias

  • varicocele

Investigation

  • semenalysis - at least 2 specimens

    • volume > 2ml

    • pH 7.2 - 8.0

    • sperm concentration > 20 million per ml

    • motility 60% forward progressive

    • morphology > 70% normal forms

    • white count < 1 million / ml

  • FSH - if low sperm count

    • low FSH - pituitary problem/tumour

    • normal FSH - blocked vas

    • high FSH - primary testicular failure

Treatment

  • surgical reconstruction of blocked vas

  • Intrauterine insemination

  • In vitro fertilisation

  • Intracytoplasmic sperm injection (ICSI)

Female

  • contraception

  • incidence of separation

  • frequency of coitus

  • dyspareunia

  • menstrual history / cycle

  • features of polycystic ovary disease

    • irregular periods

    • hirsutism

    • acne

  • features of hyperprolactinaemia

  • thyroid dysfunction

  • pelvic inflammatory disease

  • general medical history

  • past gynae history

  • previous miscarriage

  • sexual history

Examination

  • general

  • pelvic

Investigation

  • rubella immunity

  • FSH - raised >35 or not ovulating

  • LF, prolactin

  • oestrogen

  • (TFTs)

  • day 21 progesterone (or 7/7 before menstruation)

  • serial scanning

  • hysterosalpingogram

  • laparoscopy

  • hysteroscopy

  • falloscopy

  • cervical factors

  • post-coital test

  • in-vitro mucus penetration test

Treatment

  • Endometriosis

  • Ovulation induction

    • clomiphene

    • gonadotrophins

  • Assisted conception

  • Tubal surgery

    • (<30 % chance of becoming pregnant)

    • 6-9 month window after operation for best fertility

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