Infertility

When a patient consults you with concerns about difficulties becoming pregnant:
1. Take an appropriate history (e.g., ask how long they have been trying, assess menstrual history, determine coital frequency and timing) before providing reassurance or investigating further.
2. Ensure follow-up at an appropriate time (e.g., after one to two years of trying; in general, do not investigate infertility too early).
In patients with fertility concerns, provide advice that accurately describes the likelihood of fertility.
With older couples who have fertility concerns, refer earlier for investigation and treatment, as their likelihood of infertility is higher.
When choosing to investigate primary or secondary infertility, ensure that both partners are assessed.
In couples who are likely infertile, discuss adoption when the time is right. (Remember that adoption often takes a long time.)
In evaluating female patients with fertility concerns and menstrual abnormalities, look for specific signs and symptoms of certain conditions (e.g., polycystic ovarian syndrome, hyperprolactinemia, thyroid disease) to direct further investigations (e.g., prolactin, thyroid-stimulating hormone, and luteal phase progesterone testing).

General Overview

No conception after 12 months of unprotected and frequent intercourse
- Primary (no previous pregnancy)
- Secondary (after previous conception)
  - Always ask about pregnancy with other partners!
When to investigate and refer
- >1 year of trying to conceive (85% will conceive after one year)
- >35yo at 6mo
- >40yo immediately
  - Sooner if history of infertility, PID, pelvic surgery/CT/RT (in either partner), recurrent pregnancy loss, moderate-severe endometriosis

Prolactin, TSH
Ovarian reserve testing
- Day 3 FSH, LH, estradiol
  - Ovarian aging if FSH >14IU/L and high estradiol
  - Clomiphene challenge has poor predictive value
- Mid-Luteal Day 21 (or LMP -7d) progesterone
  - Progesterone >5ng/mL (15.9 nmol/L) r/o anovulatory
    - Consider repeating progesterone weekly if irregular until menses
Consider
- Clomiphene citrate challenge test (CCCT)
- AMH (anti-mullerian hormone)
- DHEA
- r/o STI (HIV, Hep B, Hep C, G+C)
Preconception
- Rubella, Varicella titres
- Pap
- Genetic testing if indicated
Imaging
- Hysterosalpingography
- Pelvic U/S (antral follicle count, r/o fibroids, cysts)
- Hysteroscopy
- Laparoscopy (endometriosis)
Semen analysis: Count (>20mill), motility (>50%), volume (2-5mL), morphology (>30%), pH, WBC (<1mil/mL)
- 3-6 days abstinence
- Repeat if abnormal in one month

Encourage weight loss if BMI >30
Stop smoking, drugs, alcohol
Anovulatory
- Consider Clomiphene Citrate 50mg PO daily x 5 days on day 3-5
  - Counsel on risks of multiple pregnancy, hyperstimulation syndorme, thrombosis, ovarian cancer
  - If no pregnancy after 3-6 cycles, refer to specialist
Referral to fertility specialist
- Ovulation induction
  - Clomiphene citrate
  - Metformin (PCOS)
  - Gonadotropin
  - Bromocriptine (to lower prolactin)
- Surgical
  - Tuboplasty
  - Lysis of adhesions
- Assisted reproductive technology (IVF, ICSI)
- Sperm/ovarian donation
Consider adoption

References:

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