Infertility

History See together Full medical history Family history useful in women Rarely indicates cause

Women Contraception Previous pregnancies Medical history Pelvic infections crohn’s disaese Surgical history Ovarain cyst, appendicectomy

Women Gynae history Cervical smear, cone biopsy PCO Hirsutism Menstrual regularity Menorrhagia Dysmenorrhoea

Women Galactorrhoea Imb/pcb Preovulatory mucous recognition Coital frequency/timing

Women Current illnesses Drugs – prescribed/recreational Social – diet, smoking, alcohol

Men Occupation Xs heat Toxins- cellulose thinners Medical history Mumps VD Surgiacl history Orchidopexy, hernia repair

Men Current illnesses Drugs – sulphasalazine Drug misuse- anabolic steroids Smoking, alcohol, caffeine Erectile dysfunction

Investigations General Rubella serolgy Fbc, Hep B,C Hiv

Investigations Sperm dysfunction Semen analysis Postcoital test

Investigations Ovulatory disorder Fsh - day 2-5 Lh – day 2-5 Testosterone Progesterone days before ovulation SHBG Tsh Prolactin

Investigations Fallopian tube damage Chlamydia serology >1:256 US contrast salpingography Hysterosalpingogram Laparoscopy and dye

Diagnostic tests Over the counter fertility tests Personna Value unclear

Management Sperm dysfunction Early referral for ivf - icsi

Management Polycystic ovaries Clomiphene days 2-6 Block oestrogen receptors Increased FSH and LH Stimulates follicular development Max use 12 months Metformin

Management Raised prolactin Drug related Specialist referral Bromocriptine Cabergoline

Management Endometriosis Medical treatment unhelpful IVF

Management Fallopian tube damage Antibiotics Early referral

Women Age > 38 Infertilty > 3 years Chlamydia antibody titre > 1:256 FSH conc. >10 iu/l LH conc. > 10 iu/l

Early referral Men Abnormal seminal fluid analysis Sperm count < 20x10 6 Sperm motility < 50% < 25% progressively motile Sperm appearance < 15% normal