INFERTILITY

INFERTILITY ( MALE & FEMALE)

• Male factor
• coital problems (Frequency, erection,psychological)
• Maternal age
• Ovulatory ( PCOS, POF, Pituitary adenoma)
• Tubal (PID, tubal damage, pelvic adhesions)
• Endometriosis, Uterine adhesions, polyps, myoma
• cervical polyps
• unexplained

HISTORY

• confidentiality & consent ( I may ask you some personal and sensitive questions, is that alright?)
• Any previous pregnancies/ miscarriages
• previous relationships/  about the partner
• how long have you been trying to conceive?
• Relationship between you and your partner?
• any problems during sex - erection/ retrograde ejaculations/ regular sex/ awareness about fertile periods

(Ask these basic questions prior to moving to exclude any pathology)

• 5 P - periods - last LMP, partner,  pills/ contraception, Pap test/STI/PID/Pelvic infections
• any weather preferences
• milky discharge from nipples, headache,visual disturbances
• acne, hirsuteness,voice change, weight change
• Change in diet/ exercise
• hot flushes/mood swings (menopausal symptoms)
• past medical history - DM, Thyroid, high blood pressure, chronic illness ( male - mumps, trauma
• gynecological procedure
• family history of sub fertility, POF

MANAGEMENT

REDUCED FREQUENCY OF INTERCOURSE

• Frequency - at least 3 times/ week
• idea about menstrual cycle and fertility period - calculate, plotting temperature, consistency of mucus
• investigations -

          semen analysis, FBE,FSH/LH/Prolactin/Estogen/TFT

          Midluteal progesterone  

          Sperm antibody screening          

          TVS

          Hysteroscopy/ hysterosalphingography

          Ovulation tests

• referral to gynecologist/ fertility clinic (where scans and further tests will be decided)
• most of the cases - cause is not known, even everythings failed options are available. (IVF/ICSI/Surrogacy?adoption) 

• reduce stress, social worker if needed,  counselling with partner, offer partner check up
• Take folic acid, review with investigation, and decision on referral - next visit

AMENORRHEA

Primary :

 Lack of menstrual flow by age 14 and absence of secondary sexual characteristics or lack   of menstrual flow by age 16 and presence of secondary sexual characteristics

PRIMARY                                                              SECONDARY                                                                                                                                                                                                                     

Imperforated hymen                                                Pregnancy/ lactation/menopause            

Genital malformation/mullerian duct agenesis    Metabolic – DM, Thyroid,
                                                                                     renal, Liver

Gonadal dysgenesis                                                Eating dis/exercise/ stress

Turner’s syndrome                                                 Drugs – contraception, danazol   

Thyroid disease                                                       Pituitary tumors

Pituitary tumor                                                        Ovary – POF, PCOS

Hypothalamic disorder                                          Ashermans syndrome

Excessive exercise                                                            

----------------------------

 HISTORY 

Confidentiality

Growth spurt

breast/axillary/ pubic hair/ height

family history - mother / sisters - menarche / menopause (if secondary)

special diet/ exercise/ laxative use/ induced vomitig

weather preferences/ neck lump/ voice change/ bowel motion

milk secretion- breast, vision change, headache

cyclical abdominal pain/ abdominal lump

breast tenderness/ early morning sickness

partner, Pregnancy, periods if secondary, pills, pap test (5P)

social history - stress

SECONDARY  (in addition to above)

Period - stopped suddenly/ gradually

           - LMP

           - menarche / how many days of bleeding/ how many days apart

           - pain,menorragia

Hot flush/ dry vagina/ pain during intercourse

Partner

Pills

pap test

pregnancy - planning to become pregnant

                 -  previous pregnancy

                 -  breast tenderness/ nausea/ vomiting

                 -  any procedures - curettage

exclude thyroid, pituitary causes + diet, exercise & stress

PCOS - excessive hair / acne/ deepening of voice

General health -  SLE, DM, any drugs, rdiation

Family history - Premature ovarian failure (POF), thyroid, PCOS

EXAMINATION 

General appearance, BMI - hirsuitism, acne

vital signs

visual fields, fundoscopy

thyroid, breast 

(axillary hair)

Abdomen - suprapubic mass

Pelvis       - external genitalia, tanner staging, speculum - imperforated hymen 

              Atrophic vaginalais/ uterus, adnexeal masses / tenderness / pregnancy test if sexually active

INVESTIGATIONS

PRIMARY                                    SECONDARY       
                                                 

FSH/LH/Prolactin/Estradiol          FBE,BSL,U & E, BSL

Chromosomal analysis                      FSH,LH,Estradiol,Prolactin,TFT

Pelvic USS/ Vag/ PT                          Pelvic USS

TFT, FBE                                              Bone density

                                                                    CT/MRI – Pituitary tumor

MANAGEMENT 

physiological/ constitutional/ familial

• 1st period usually occurs after 2 years of breast development, individual variation presents
• referral to gynecologist
• hormonal challenge test if needed
• (hand book) review with investigations --- no periods after 1 years --- repeat estradiol

excessive exercise

• investigate to exclude other causes
• advise on exercise, referral to dietician, gynaecologist
• (Ca, Vit D, OCP/HRT to prevent osteoporosis)

Asherman's syndrome

• investigation - pregnancy test, hormones, USS
• explain the procedure - curettage --- complications --- formation of adhesion/ scars/ bands
• referral to gynecologist

            - hysteroscopy - small flexible optic tube is inserted through the cervix to see the uterine

                                       cavity ---intrauterine adhesion --- cut 

            - contrast X Ray study - to define the scar tissues & uterine structure

            - Estrogen - to repair the lining 

            - complications of hysteroscopy - uncommon, anesthetic risk, infection, bleeding, pain

            - effectiveness depends on the extent of the disease

Post pill amenorrhea (HAND BOOK)

• Gradual reduction of periods - ASK!!!
• The pill causes thinning of the womb lining (female hormone - progesterone)
• Investigate to exclude other causes
• this is reversible once the pill is stopped
• either continue with OCP if no concerns or change to other forms or micrognon 50/ Triphasic pills
• referral to specialist if necessary