1. Infertility

2. Definitions Failure to conceive within 2 years of regular unprotected intercourse. Primary or secondary. 84% of couples will conceive within 1 year and 92% within 2 years.

4. Management History Couple should be seen together and reassured. Woman’s age and duration of infertility. Any history suggestive of a cause. Investigate after one year of failure to conceive. Investigate sooner if > 35 or history suggestive of problems.

5. Examination Female BMI Hyperandrogenism Galactorrhea Pelvic abnormalities Male Assess genitalia if history suggestive or semenalysis abnormal

6. Reassure women with regular cycles. Advice re timing and frequency of intercourse. Avoid alcohol, smoking, drugs. Folic acid. Weight.

7. Baseline investigations Female Follicular phase LH, FSH, oestradiol Luteal phase progesterone Rubella Consider tubal patency test (chlamydia test first) Male Semenalysis & repeat at 3 months if abnormal

8. Volume >2ml pH 7-8 Concentration >20 x 10 6 /ml Motility >50% forward & >25% with rapid linear progress Morphology > 15% normal Alive > 50% Antisperm antibodies Negative WCC< 1x10 6

9. Treatment Male Factor Hypogonadotrphic hypogonadism – gonadotrophins Obstructive azoospermia – surgical correction Correction of varicocele

10. Anovulation Clomiphene days 2-6 for up to 1 year. Monitor with ultrasound for 1 st cycle. Gonadotrophins – FSH for 10 days followed by hCG. Ovarian drilling Metformin (evidence lacking)

11. Tubal Disease Ablate endometriosis at the time of laparoscopy Tubal surgery IVF

12. Intrauterine Insemination Used in unexplained or mild male factor infertility. Outcome may be no better than expectant management.

13. IVF Pituitary suppression – GnRH agonist Superovulation – FSH (hyperstimulation) hCG to mimic LH surge Oocyte collection Fertilisation & incubation (ICSI) Embryo transfer 48-72 hours later Luteal support with progesterone

16. Take-home baby rate 20% per cycle. Consider alternatives: oocyte/sperm donation surrogacy adoption