assessment & treatment for fertility problems: the role of primary care michael booker...

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Assessment & Treatment for Fertility Problems:

The Role of Primary CareMichael Booker

Consultant OB / GYNSpecialist in Reproductive Surgery &

Fertility Treatment


When will couples first seek advice?

• 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


• “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


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


Female Fertility: Lifestyle Factors

• Eat a well balanced diet• Have a sensible BMI• Exercise regularly• Role of supplements• Folic acid 400mcg• Adjustments to reduce

stress


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


Male Fertility: Lifestyle Factors

• Eat a well balanced diet• Have a sensible BMI• Exercise regularly• Adjustments to reduce

stress• Role of anti-oxidants

and supplements


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


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


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


Infertility is a marker formedical disease

• For men• For women


Initial Investigations

• UK guidelines• Guidelines from other countries• Local guidelines• Medical textbooks• Medical journals• Internet


Semen analysis (WHO 2010)

• 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


Male Fertility Assessment: Lab Tests

If count is less than 5 x 10/6 on two semen analyses:FSH, LHTestosteroneTSH, ProlactinAnd if any erectile dysfunction:Fasting lipids


Female Fertility: Initial Lab Tests

• FSH LH (Day 2 – 5)• Oestradiol (Day 2 – 5)• TSH• Prolactin• Full Blood Count• Hb Electrophoresis• Rubella Status

• Cervical smear• Endocervical swabs• - bacteriology• - chlamydia


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


Ovarian Reserve Assessment

• 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


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


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”


But my hormone levels are normal!


Female Fertility: Baseline TV Scan

• Assess Ovarian size and morphology

• Any cysts?• Hydrosalpinges• Free fluid• Fibroids• Congenital uterine

malformations


Female Fertility: Extra lab tests for PCO

• Fasting cholesterol• Fasting blood glucose• Testosterone


PCO: Endocrine Markers

• 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


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


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


Primary and Secondary Care:Effective Interfacing

• Working together• Couples will rely on

primary care professionals for support during complex investigations and treatments


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


Secondary Care: Principles

• Further investigations: • Cycle monitoring, tubal patency testing,

hysteroscopy, laparoscopy• Establishing a diagnosis• Planning treatment


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


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


Thank you for your attention!

assessment & treatment for fertility problems: the role of primary care michael booker...

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