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Fertility and Subfertility

Investigations into infertility should be started in couple who've been struggling to actively conceive for 12 months.


General advice initially given to couple struggling to conceive include:

  • Woman should be taking 400mcg Folic acid OD

  • Aim for healthy BMI – don’t excessively exercise

  • Avoid smoking and drinking excessively

  • Reduce stress

  • Avoid timing intercourse – Not necessary/recommended as it can lead to increased stress and pressure in the relationship


Causes:

  • Sperm problems – 30%

  • Ovulation problems – 25%

  • Unexplained – 20%

  • Tubal problems – 15%

  • Uterine problems – 10%

  • Genetics


Investigations

Chlamydia and Gonorrhoea screen should be done for both the male and female as PID can cause tubal adhesions.


Just for the male - Semen analysis

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“Abnormal sperm” © Xenzo CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0/)

Just for the female:

  • BMI – Low could indicate anovulation, High could indicate PCOS

  • Female hormonal testing – LH, FSH, Progesterone, AMH, Thyroid, Prolactin

    • High LH suggests PCOS

    • High FSH suggest poor ovarian reserve (follicular count)

    • Rise in Progesterone suggests ovulation has occurred

    • High AMH suggests good ovarian reserve (follicular count)


Imaging and Special tests:

  • Pelvic US – look for any structural abnormalities

  • Hysterosalpingogram – look at tubal patency

  • Laparoscopy and Dye test – look for tubal patency, adhesions and endometriosis


Management

If a sperm problem:

  • Surgical sperm retrieval

  • Surgical correction of obstruction in vas deferens

  • Intra-uterine insemination – collecting and separating out the high-quality sperm, then injecting them directly into the uterus

  • Sperm donation


If an ovulation problem:

  • Weight loss for PCOS patients can restore ovulation

  • Clomifene to stimulate ovulation – Letrozole and Gonadotropins are other options

  • Ovarian drilling in PCOS – reduces testosterone production, therefore stimulating ovulation


If a tubal problem:

  • Tubal cannulation

  • Laparoscopy to remove adhesions and endometriosis

  • IVF


If a uterine problem:

  • Surgery for polyps, adhesions and other structural problems affecting fertility



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