1. Specialist in Reproductive Surgery &
Assessment & Treatment for Fertility Problems: The Role of Primary Care
Michael Booker
Consultant OB / GYN
Specialist in Reproductive Surgery &
Fertility Treatment

2. 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

3. “It must be remembered that infertility is often a reversible state”
“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

4. 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
Excessive alcohol reduces fertility and increases risk of fetal alcohol syndrome

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Infertility is a marker for medical disease
For men
For women

12. Initial Investigations
UK guidelines
Guidelines from other countries
Local guidelines
Medical textbooks
Medical journals
Internet

13. 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

14. 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

15. 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

16. Female Fertility: Thyroid disease
Ovarian function
… and in pregnancy
Even quite subtle thyroid disease can affect ovarian function
Concept of “crosstalk” between thyroid hormones and FSH & LH
Family history provides clues
Review by an endocrine physician
For hypothyroid women, dose of thyroxine needs to increase

17. 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

18. 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

19. 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”

20. But my hormone levels are normal!

21. Female Fertility: Baseline TV Scan
Assess Ovarian size and morphology
Any cysts?
Hydrosalpinges
Free fluid
Fibroids
Congenital uterine malformations

22. Female Fertility: Extra lab tests for PCO
Fasting cholesterol
Fasting blood glucose
Testosterone

23. 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

24. 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

25. 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

26. Primary and Secondary Care: Effective Interfacing
Working together
Couples will rely on primary care professionals for support during complex investigations and treatments

27. 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

28. Secondary Care: Principles
Further investigations:
Cycle monitoring, tubal patency testing, hysteroscopy, laparoscopy
Establishing a diagnosis
Planning treatment

29. Fertility Treatment Male Female Treatment for endocrine disease
Optimising cardiovascular health
Varicocelectomy
Vasovasostomy
Vasoepididymostomy
Treatment for endocrine disease and PCO
Surgery for endometriosis
Myomectomy
Tubal microsurgery
Correction of congenital uterine malformations
Hysteroscopic surgery
Ovulation induction

30. 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

31. Thank you for your attention!