Assessment & Treatment for
Fertility Problems:
The Role of Primary Care
Michael Booker
Consultant OB / GYN
Specialist in Reproductive Surgery &
Fertility Treatment
www.fertility-info.co.uk
When will couples first seek advice?
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If no conception within 1 year, or earlier:If the woman is older (>36yrs)
Infertile in a previous relationship
Significant past history, eg
- Previous ectopic pregnancy
- Previous gynae surgery
- Undescended testicles
www.fertility-info.co.uk
• “When those who desire children are
unsuccessful in conceiving, their frustration
can turn to despair, helplessness, and the
need to seek advice from any source”
• “It must be remembered that infertility is
often a reversible state”
• Gary M Horowitz 2007
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Female Fertility: Lifestyle Factors
• Alcohol: max 4 units/wk
• Excess alcohol reduces
fertility & causes fetal
alcohol syndrome
• Smoking reduces
fertility (lowers AMH)
• Smoking increases
pregnancy
complications
• Obesity BMI>30 :• Delays conception
• Increases risk of
miscarriage &
pregnancy
complications
• Underweight BMI<20
• - causes anovulation
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Female Fertility: Lifestyle Factors
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Eat a well balanced diet
Have a sensible BMI
Exercise regularly
Role of supplements
Folic acid 400mcg
Adjustments to reduce
stress
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Male Fertility: Lifestyle Factors
• Obesity BMI>30 impairs
fertility
• Smoking increases
reactive oxygen species
• Tobacco contains
cadmium (heavy metal)
• Excessive alcohol
damages sperm
production
• Heart disease is
associated with male
infertility and erectile
dysfunction
• Anabolic steroids
damage sperm
production
• Other environmental
toxins
• Avoid tight underpants
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Male Fertility: Lifestyle Factors
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Eat a well balanced diet
Have a sensible BMI
Exercise regularly
Adjustments to reduce
stress
• Role of anti-oxidants
and supplements
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Coital Frequency
• Enquire about coital
difficulties
• Coitus every 2-3 days
• Detecting LH surge for
women with regular
cycles
• Effects of lifestyle, long
hours at work, travelling
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Female Fertility: Medical History
• Review details of past
medical / surgical
history
• Optimise treatment of
any ongoing health
problems
• Review medications
• PID / STI history
• Previous pregnancies
• Menstrual history
• Any gynaecological
symptoms?
• Physical examination
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Male fertility: Medical History
• Review details of past
medical history
• Optimise treatment of
any ongoing health
problems
• Review medications
• STI history
• Heart disease risk
• Previous pregnancies
• Surgery for
undescended testes
• Inguinal hernias
• Testicular torsion ops
• Mumps
• Physical exam if
indicated
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Infertility is a marker for
medical disease
• For men
• For women
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Initial Investigations
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UK guidelines
Guidelines from other countries
Local guidelines
Medical textbooks
Medical journals
Internet
www.fertility-info.co.uk
Semen analysis (WHO 2010)
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Volume >1.5mls
pH >7.2
Sperm concentration >15 x 10/6 per ml
Total sperm count > 39 x 10/6
Motility >40 %, >32% progressive motility
Morphology >4% by strict criteria
WBC <1 x 10/6 per ml
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Male Fertility Assessment: Lab Tests
If count is less than 5 x 10/6 on two semen
analyses:
FSH, LH
Testosterone
TSH, Prolactin
And if any erectile dysfunction:
Fasting lipids
www.fertility-info.co.uk
Female Fertility: Initial Lab Tests
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FSH LH (Day 2 – 5)
Oestradiol (Day 2 – 5)
TSH
Prolactin
Full Blood Count
Hb Electrophoresis
Rubella Status
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Cervical smear
Endocervical swabs
- bacteriology
- chlamydia
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Female Fertility: Thyroid disease
Ovarian function
• Even quite subtle thyroid
disease can affect ovarian
function
• Concept of “crosstalk”
between thyroid hormones
and FSH & LH
• Family history provides
clues
… and in pregnancy
• Review by an endocrine
physician
• For hypothyroid women,
dose of thyroxine needs to
increase
www.fertility-info.co.uk
Ovarian Reserve Assessment
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FSH LH Oestradiol (Day 2 – 5 of cycle)
Transvaginal Ultrasound of Ovaries
- Antral Follicle Count
Anti Mullerian Hormone (AMH)
Past medical / surgical history
Past reproductive history
Age
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Ovarian Reserve Assessment
• Fluctuating levels of FSH; The high levels are
more significant than the low levels
• Oestradiol should be low normal at day 2 – 5;
paradoxically high levels signify
ovarian/pituitary dysynchrony
• Low AMH can be the only biochemical marker
for diminished ovarian reserve
• Careful TVUSS assessment of ovaries
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Anti Mullerian Hormone
• Rises in adolescence
• Reaches a peak in early 20’s
• Followed by an initial steep fall and then a long
slow further decline
• Reported in centiles:• 75 – 100% “Optimal fertility”
• 50 – 75% “Satisfactory fertility”
• 25 – 50% “Low fertility”
• 0 – 25% “Very low / undetectable”
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But my hormone levels are normal!
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Female Fertility: Baseline TV Scan
• Assess Ovarian size and
morphology
• Any cysts?
• Hydrosalpinges
• Free fluid
• Fibroids
• Congenital uterine
malformations
www.fertility-info.co.uk
Female Fertility: Extra lab tests for PCO
• Fasting cholesterol
• Fasting blood glucose
• Testosterone
www.fertility-info.co.uk
PCO: Endocrine Markers
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Reversed FSH:LH ratio
Raised testosterone
Type II diabetes (x7 risk)
High cholesterol
LDL chol higher than
HDL chol
• Raised triglyceride
• Also look for
• - Hyperprolactinaemia
• - Thyroid disease
www.fertility-info.co.uk
Male fertility: Effect of Ageing
• Little change with age
up to age 40yrs
• Over 40, decline in
testosterone levels
(Leydig cells)
• Decline in
spermatogenesis
(Sertoli cells)
• Testosterone
supplements don’t help
www.fertility-info.co.uk
When to refer?
• “People who experience fertility problems
should be treated by a specialist team because
this is likely to improve the effectiveness and
efficiency of treatment and is known to
improve people’s satisfaction with treatment”
• NICE 2013
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Primary and Secondary Care:
Effective Interfacing
• Working together
• Couples will rely on
primary care
professionals for
support during complex
investigations and
treatments
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Primary care to Secondary Care
• “The purpose of the basic infertility workup is
to (1) identify the likely basis of the underlying
obstacle or obstacles and suggest the best
evidence-based therapies, and (2) bring
understanding and identity to our patients.
This regard for the psychological well-being of
our patients will help guide them toward
successful closure regardless of the success or
failure of their treatment” Gary M Horowitz
www.fertility-info.co.uk
Secondary Care: Principles
• Further investigations:
• Cycle monitoring, tubal patency testing,
hysteroscopy, laparoscopy
• Establishing a diagnosis
• Planning treatment
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Fertility Treatment
Male
• Treatment for endocrine
disease
• Optimising cardiovascular
health
• Varicocelectomy
• Vasovasostomy
• Vasoepididymostomy
Female
• Treatment for endocrine
disease and PCO
• Surgery for endometriosis
• Myomectomy
• Tubal microsurgery
• Correction of congenital
uterine malformations
• Hysteroscopic surgery
• Ovulation induction
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Fertility Treatment: Male & Female
• Ovulation induction with intrauterine
insemination
• Donor sperm treatments
• IVF
• IVF + ICSI
• Donor oocyte IVF
• IVF with Pre-implantation genetic diagnosis
• Oncofertility
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Thank you for your attention!
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