Infertility

Infertility

Jul 8, 2020 2
o&g,onthepods

Svetha Rao talks to Louis Angelopoulos about what constitutes infertility, common causes and how to approach a couple who presents with infertility.

Summary Writer:  Jane McDonnell

Script Writer:  Jane McDonnell, Svetha Rao

Editor:  Svetha Rao

Interviewee:  Louis Angelopoulos

About Dr Svetha Rao

Dr Svetha Rao is a third-year Obstetrics and Gynaecology trainee. She calls Sydney home and is undergoing her basic training through Liverpool hospital. Svetha loves the high risk and high reward aspect of obstetrics. 

Aside from catching babies, she enjoys long walks on the beach and working on her down-facing dog.

About Dr Louis Angelopoulos

Dr Louis Angelopoulos is a Staff Specialist in Obstetrics & Gynaecology at Gosford General Hospital, Central Coast, NSW, Australia. After graduating from medicine in South Africa at Stellenbosch University, Louis commenced his Obstetrics & Gynaecology training in 2003 in the Oxford Deanery of England, working in hospitals in the Thames Valley, completing his Certificate of Completion of Training in 2009. After working in the Royal Berkshire NHS Trust for two years, he moved to Australia. Louis has a strong interest in medical education and speaks both English and Afrikaans.

Infertility

With Dr Louis Angelopoulos, Obstetrics & Gynaecology Staff Specialist at Gosford Hospital, New South Wales, Australia

Introduction

There are many causes of infertility so a systematic approach to its investigation is useful. Treatment methods are based on the underlying cause.

Case

Jenny and John are a couple who present to the fertility clinic after 8 months of timed, unprotected intercourse without conceiving. Jenny is 37 years of age and John is 40 years of age. They are anxious that the ‘clock is ticking’. Neither has any live children, nor any significant medical history.

  • Inability of a couple to conceive after 12 months of regular intercourse without contraception.
    • Between 80% and 90% of couples will conceive in this time period.
    • Despite this, we may evaluate a cause of infertility sooner than this period if there are factors which may contribute to reduced fertility such as:
      • Maternal age over 35 years of age.
      • Women with a history of irregular menstruation, chemotherapy, radiation therapy or tubal/uterine disease such as advanced endometriosis.
      • Men with a history of a groin surgery, chemotherapy, adult mumps or sexual dysfunction.
  • Clinical history
    • Regularity of menstruation – indicator of ovulation
    • Whether either member of couple has live children – differentiate primary and secondary infertility
    • General past medical history including any autoimmune diseases or chemotherapy/radiotherapy
  • On examination
    • BMI
    • Evidence of endocrine abnormalities including hypo- or hyperthyroidism
    • Features of genetic conditions (e.g. Turner syndrome in women, Klinefelter syndrome in men)
  • Causes broken down into female causes, male causes and combination of the two.
  • Often multiple factors contribute and it may be difficult to determine which is the main contributor.
  • Ovarian causes
    • Women who do not ovulate or ovulate infrequently don’t have an oocyte available for fertilization (e.g. PCOS)
    • Oocyte ageing ? decline in oocyte quality and quantity
  • Tubal causes
    • Transport of the oocyte and sperm is inhibited by tubal disease and pelvic adhesions, usually caused by pelvic inflammatory disease (secondary to, for example, chlamydia or gonorrhoea)
    • Adhesions from previous surgery
    • Severe endometriosis
  • Uterine causes
    • Uterine fibroids that have a submucosal or intracavity component may contribute to infertility and there is evidence that their removal can increase fertility rates
    • Uterine abnormalities such as Mullerian anomalies or a septate uterus can interfere with normal implantation
  • Less common causes
    • Cervical abnormalities such as congenital malformations or trauma
    • Some autoimmune diseases
    • Genetic disorders such as Turner syndrome (45, X)
  • Over 80% of infertile men have low sperm concentrations
  • Testicular defects in spermatogenesis (formation of sperm)
    • Most commonly, idiopathic dyspermatogenesis – abnormalities in sperm number, shape or motility without an identifiable cause
    • Genetic causes such as Y chromosome defects, autosomal or X chromosome defects,
    • Klinefelter syndrome
    • Cryptorchidism (undescended testes can result in reduced quality or quantity sperm)
    • Varicocele (dilation of the pampiniform plexus)
    • Infection – especially adult mumps
    • Environmental factors such as smoking or hyperthermia (men should wear loose boxer shorts)
    • Anti-sperm antibodies
  • Endocrine disorders such as hypothalamic or pituitary disease
    • Idiopathic hypogonadotrophic hypogonadism or GnRH deficiency
    • When this is associated with anosmia, it’s called Kallmann syndrome
    • Congenital combined pituitary hormone deficiency
    • Pituitary macroadenomas or other sellar masses cause hypogonadotrophic hypogonadism, as can infiltrative diseases such as sarcoidosis or tuberculosis, or head trauma or intracranial radiation
    • Congenital adrenal hyperplasia
    • Hypo- or hyperthyroidism
  • Sperm transport disorders
    • Abnormalities of the epididymis or vas deferens (such as obstruction)
    • Ejaculatory duct disorders – spinal cord disease can cause decreased or retrograde ejaculation
    • Erective dysfunction
  • Idiopathic male infertility – this is different from idiopathic dyspermatogenesis because there is normal seminal fluid analysis
  • Investigations will depend on history and examination but some of the basic investigations include:
    • Semen analysis – quantity, morphology and motility of sperm
    • Day 3 serum FSH and oestrodiol levels, anti-Mullerian hormone (AMH) for ovarian reserve
    • LH surge prior to ovulation and day 21 progesterone (in normal 28 day cycle)
    • TSH levels
    • Hysterosalpingogram or sonohysterogram for tubal patency and uterine cavity abnormalities
      • +/- Pelvic USS for uterine myomas
      • +/- Laparoscopy for endometriosis or other pelvic pathologies
  • As many as 15% couples have unexplained fertility
  • Adopt approach that is least to most invasive and resource-intensive
  • Lifestyle advice (smoking cessation, healthy weight, reduce alcohol, caffeine, recreational drugs)
  • Assisted reproductive technology (ART)
    • It is estimated that one in 22 babies born in Australia today is conceived using ART
    • Intrauterine insemination: ejaculated semen injected into uterine cavity (can only be offered if there is a normal semen analysis)
    • May be paired with clomophine citrate (induces ovulation) or an aromatase inhibitor (e.g. letrozole)
    • If unsuccessful, may progress to in vitro fertilization (IVF)
    • IVF has the highest per cycle pregnancy rate in the shortest time interval
  • Don’t forget male factors
    • Quantity and quality of sperm declines as males age (over 45 years old)
    • Female partners of men over 45 take 5x longer to conceive than those with partners 25 or less
    • As men age, the risk of chromosomal abnormalities and birth defects in the children increases
    • Children of older fathers have an increased risk of having an autism spectrum disorder
  • Regarding the COVID-19 pandemic, there has been no adverse impact on fertility rates or pregnancy-related complications

Related Podcasts

Related Blogs

Tags: #conceiving,#diagnosis,#fertility,#fertility clinic,#infertility,#Klinefelter syndrome,#O&G,#obstetrics and gynaecology,#oocyte,#ovarian causes,#ovaries,#tubal disease,#Turner syndrome

If you enjoyed listening to this week’s podcast feel free to let us know what you think by posting your comments or suggestions in the comments box below.

If you want to listen to this episode while not connected to WiFi or the internet, you can download it. To find out more go to Apple support (https://support.apple.com/en-us/HT201859)

2 Comments

  1. Issam Adam

    August 4, 2020 at 3:54 am

    Very useful information.
    thank you so mach

    Reply

  2. Narayan

    August 7, 2020 at 2:43 am

    Very useful and concise note which would be a good source of quick review. Thank you for posting such podcast.

    Reply

Leave a comment:

Your email address will not be published. Required fields are marked *

onthewards is a registered trademark (1784140) which is approved by the ACNC as a registered charity | ABN 51 198 764 539
 
This work is licensed under a Creative Commons Attribution 2.0 Generic License