Overview

• Subfertility → woman of reproductive age that has not conceived after 1 year of regular, unprotcted sexual intercourse.
  • Causes → female problem (30-40%), male problem (25-30%), unexplained (20%).
    • Female → ovulation failure (20%), tubal damage (15%), cervical and uterine anomalies, chromosomal abnormalities.
  • Lifestyle Risk Factors → increased maternal age, BMI >30, smoking/alcohol/drugs, anorexia/excessive exercise.
• Female Causes ⇒
  1. Hypothalamic-Pituitary Failure (Hypogonadotrophic Hypogonadism).
     • Low gonadotrophins + low oestrogen.
     • Causes → low weight, excessive exercise, kallman’s syndrome, sheehan’s syndrome.
  2. Hypothalamic-Pituitary-Ovarian Dysfunction (Normogonadotrophic Normogonadism).
     • Normal gonadotrophins + normal oestrogen.
     • Causes → PCOS.
  3. Ovarian Failure (Hypergonadotrophic Hypogonadism).
     • High gonadotrophins + low oestrogen.
     • Cause → premature ovarian insufficiency.
  4. Prolactinaemia or Thyroid Disease → prolactinoma, primary hypothyroidism, chronic renal failure, drugs.
  • Tubal Disorders → infection (PID), adhesions, endometriosis, salpingectomy.
  • Uterine Anomalies → fibroids, ashermans.
• Male Causes ⇒
  • Cryptorchidism
  • Varicocele
  • Absence of Vas Deferens (CF)

Making Diagnosis

Clinical Features

Investigations

• Male → semen analysis (2 tests, 3 months apart): if azoospermia, most commonly due to varicocele.
• Female → mid-luteal (day 21) progesterone (confirm ovulation).
  • If Irregular Cycles → indication to also do progesterone (prolonged irregular cycles) and day 2/3 LH/FSH (irregular cycles).
  • Blood Hormonal Profile (Serum Gonadotrophins)
  • TVUSS (Uterine Abnormalities)
  • Tubal Assessment (if hormonal profile is normal) → no co-morbidities: hysterosalpingography (HSG - PURELY IMAGING)), co-morbidities (hx of PID, ectopic, endometriosis): laparscopy and dye (imaging AND treatment).
• Both → Chlamydia (STI) Screen.

Management Plan

• 1st Line → wait until regular intercourse established for at least 12 months (every 2-3 days).
  • Key Information → BMI 20-25, folic acid, regular intercourse (every 2-3 days), smoking/drinking advice.
  • Perform investigations after 12 months.
• 2nd Line → unexplained sub-fertility, mild endometriosis, or ‘male factor’ sub-fertility → try for another 12 months.
• Medical Management
  • Ovulation Induction → anovulation (PCOS, idiopathic).
    • 1st Line → clomiphene.
    • 2nd Line → FSH and LH injections (Gonadotrophins).
    • 3rd Line → pulsatile GnRH or DA agonists.
• Surgical Management
  • Operative Laparoscopy → adhesions, ovarian cyst, endometriosis.
  • Myomectomy → fibroids.
  • Tubal Surgery → blocked tubes amendable to repair.
  • Laparoscopic Ovarian Drilling → PCOS unresponsive to medical management.
• Assisted Conception
  • Intrauterine Insemination (IUI) → sperm is placed into woman’s uterus at time of ovulation.
  • IVF → patients with tubal pathology whose treatment wasn’t successful.
  • Intracytoplasmic Sperm Injection (ICSI) → most common treatment for male infertility. Sperm injected directly into egg. Used if oligospermia (low sperm count).
  • Donor Insemination → presence of azoospermia (no sperm production).
  • Donor Egg with IVF → egg quality is poor or ovarian failure (eg. chemotherapy where ovarian function was affected).