Management of infertility in general practice

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Rohan subasinghe
Some facts
 Affects 1 in 6
 Fertility declines with age
 84 % - cumulative prob of pregnancy in 1st yr
 92 % - cumulative prob of pregnancy in 2nd yr
 Infertility is failure to conceive after regular
unprotected intercourse for 2 yrs in absence of known
reproductive pathology
Initial management
 Early investigation in – people with predisposing
factors
 Both partners – couple based
 Rubella status
 Folic acid while trying to concieve (0.4-5 mg)
 Explain each stage of investigation
 Detalied rug hx, drug abuse, alcohol etc
General advice
 Give up smoking
 Alcohol - 2 units for women 2-4 units for men
 BMI in women– 19-29
 Men with poor quality sperm – loose underwear
 Regular intercourse throughout cycle
 No evidence for temperature charts
Initial investigations
 Semen analysis – check twice
 Serum progesterone in mid-luteal stage
 Serum gonadotrophins
 No value in thyroid/prolactin in absence of pathology
and in th presence of a regular cycle
Semen analysis
 Abstain for 3 days
Vol – 2-5ml
Liquefaction tuime – within 30 mins
Concentration - >20 mill/ml
Motility - >50 %
Morphology - >30 %
Wbc - <1 mill/ml
Mid-luteal progesterone
 7 days before period in 28 day cycle
 Timing crucial
 Adjust for longer periods
 <16 nmol/l –repeat – refer if consistently low
 >16 but <30 – repeat - if same or lower – refer
 >30 – proof of ovulation
Flow chart - RCOG
 http://www.gp-
training.net/protocol/gynaecology/infert2.htm
Fertility algorithm - NICE
 http://www.rcog.org.uk/resources/public/pdf/fertility
_algorithm.pdf
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