Managing unwanted
childlessness
Dr Jodie Semmler
fertility SA
Dr Louise Hull
Senior lecturer in reproductive medicine
WCH, University of Adelaide and
fertility SA
‘For unflagging
interest and
enjoyment,
all other forms of
success lose their
importance in
comparison to a
household of
children’
Theodore Roosevelt
Age makes a difference
Lifestyle Advice
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Intercourse every 2-3 days optimises conception
Fertile times of the cycle
Moderate alcohol intake (no binges)
Stop smoking
Optimal BMI between 19 and 25
Avoid Drugs
Avoid occupational exposures to solvents etc
Folic acid, Vit B 6 and 12 supplements, Omega 3
Vitamin supplementation (Vit E and Selenium)
Causes of difficulty conceiving
Eggs
Sperm
Need to meet
EGGS!
Assessing Ovulation
• Are your cycles regular?
• Mid luteal prog – day 21 if
day 28 cycle, day 28 if 35
day cycle (timing critical)
• Basal body temperature
• LH kits
• Cycle tracking
Ovarian Reserve
Ovarian reserve may be reduced even
if ovulatory
Assess with egg timer test day 3-5
FSH
AMH
ovarian volume and antral follicle count
If low ovarian reserve
–prompt referral for fertility advice.
Associated with poor response to gonadotrophins,
possibly poor oocyte and embryo quality if
markedly reduced, ?increased miscarriage
Anovulation
• Hypothalamic dysfunction (normal FSH/LH)
• Hypogonadotrophic hypogonadism (low FSH/LH)
• Premature menopause (high FSH/LH)
• Hyperprolactinaemia (high PRL)
• Abnormal thyroid function (high TSH)
• Polycystic ovarian syndrome
• Tests- day 3 FSH, LH, PRL, TSH, androgens if
suspect PCOS
• USS pelvis –ovarian reserve, PCOS
Hypothalamic Dysfunction
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Simple Environmental Causes
Exam/ other stress
Travel
Perimenarchal
• Weight related Causes
• Anorexia/malnutritian
• Exercise induced amenorrhoea
• Psychiatric
• Depression
• Organic Causes (pan hypopit)
• Brain tumors –need MRI
• Endocrine disorders
Ovarian Failure
high FSH and LH and low E2,
normal prolactin and thyroid
Further Investigations may include:
chromosomes
autoantibody screen
bone mass
lipids
Treatment –
donor oocyte programme
estrogen replacement therapy
counselling
Prolactin
• Elevated prolactin on 2
occasions
• Galactorrhoea, breast
discomfort, visual field
abnormalities
• MRI/CT pituitary
• Treat with Carbergoline
(0.5mg weekly)
Thyroid disorders
TSH to screen
• Symptoms
• Goitre/thyroid
enlargement
• Referral to
endocrinologist/surgeon
for treatment and
ongoing care.
Polycystic ovarian syndrome
2 out of 3 of:
• Oligo/ammenorrhoea
• Clinical and/or biochemical signs of hyperandrogenism
• Ultrasound
• And exclude other causes of anovulation
PCOS consensus agreement
ESHRE/ASRM (Rotterdam)
2003
Hum. Reprod, (2004)
19,1:41-47
PCOS Investigations
Investigations:
Insulin resistance (blood glucose)
Lipids
Endometrial thickness
PCOS fertility
treatment
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Weight loss
Clomiphene
Metformin
Ovulation Induction with FSH
Ovarian drilling
IVF –risk of OHSS
Ovulation Induction
Sperm
Male Factor Disorder
• History
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Previous surgery/trauma
Congenital problems
Infections (mumps orchitis/STDs)
Other illnesses (cancer/chemotherapy)
Smoking, drinking, drugs
Occupational exposures
Semen Analysis
More than 1 semen Analysis usually
required (3 months apart)
• Normal SA
• >20 million per ml
• >50% forward motility
• >3% normal morphology
(WHO strict criteria)
Other sperm defects
• Kruger et al 1986 (strict morphological criteria)
• <15% normal morphology (old criteria) associated with
reduced IVF fertilisation even with normal counts. No
data yet with new reference ranges, 4% normal shapes is
5th centile, may be fertilisation issue if less than eg 8%
• ICSI restored fertilisation rates
Investigation of an abnormal
semen Analysis
• If semen Analysis abnormal
- repeat S.A.
• If mild/ moderate oligozoospermic (majority)
- IUI/IVF/ICSI
• If azoospermic/severe oligozoospermia
-further investigations
Investigations of Severe Semen
Defects
FSH/LH/testosterone/PRL/TSH
If abnormal then MRI pituitary
USS testes (tumour)
Chromosomes/CF mutations/Y chromosome
deletions
Management
Hypogonadotrophic hypogonadism
-FSH treatment
Mild sperm defects -IUI
Testicular failure -ICSI/TESA/donor sperm
Obstructive azoospermia -PESA/TESA
Intrauterine Insemination
15-40% chance of pregnancy
over 3 cycles (very dependent
on patient selection)
FSH Injections to ensure 1 or 2
eggs present at insemination
Need patent fallopian tubes
Risk of multiple pregnancy
Low sperm morphology ,
unexplained and endometriosis
patients do poorly
PESA/TESA
ICSI
IVF+/- ICSI approx 50% chance of pregnancy in 1
cycle if < 38yrs
Meeting up
Assessing Sexual dysfunction
(5%)
• Male history important
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How often do you make love?
Do you get erections?
Can you penetrate your partner deeply?
Do you reach orgasm?
Do you ejaculate?
Assessing Tubal Damage
• Have you had tubal surgery, endometriosis, painful
periods, appendicitis or infections like chlamydia?
• If no- HSG (reliable indicator of tubal patency not
obstruction)
• If yes- consider laparoscopy and dye
• History of Tubal ligation/reversal – high
chance tubal issues
• Congenital anomalies - best assessed by MRI, 3D
ultrasound, Hy Cosi or saline sonogram. HSG not as
accurate for this
Endometriosis
Tubal damage,
Oxidative damage to oocytes/embryos
Eutopic endometrial changes (implantation problems)
Painful intercourse
Management: Surgery, GnRH agonists before IVF
Other causes
Unexplained
Failed Fertilisation
(5-10% IVF cycles)
Implantation Failure
Recurrent Miscarriage
IVF
Who needs referral?
Referral to Fertility Services
• All couples concerned about fertility should
be offered a consultation
• Further investigation should be offered after
1 year of failing to conceive
• Earlier investigation should be offered to:
– Women >35 years
– History suggestive of anovulation, tubal
disease, pelvic surgery, endometriosis or male
factor problems
– Family history of early menopause
The goal of treatment
A single
healthy baby
born at term