Infertility
This booklet is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
Infertility is defined as failure by a couple to conceive after a year of regular sexual intercourse. This is a common problem at all levels of care. 50% those presenting at 1 year will conceive without assistance. Some patients present with infertility, others indirectly, with complaints of lower abdominal pain, abnormal vaginal bleeding etc. All nulliparas in their thirties should be asked specifically if they have an infertility problem, otherwise the true reason for presenting symptoms may be missed.
Many government hospitals are not equipped to investigate & manage infertility properly, & are unable to treat most couples.
Common causes of Infertility
- Tubal factor (most frequent) – mostly chronic PID, also endometriosis
- Male factor (also very common)
- Uterine factor – fibroids, Asherman’s syndrome, tuberculosis (rare in SA)
- Ovarian factor – anovulation, PCOS, premature menopause
- Hypothalamic / pituitary factor – underweight, severe stress
- Couple factor – infrequent intercourse or poor coital technique
- Other causes – congenital abnormalities, chromosomal abnormalities etc.
- Unexplained – some couples fail to achieve pregnancy, for unknown reasons (= or > 20% in most series)
History & Examination
- Establish whether the couple is truly infertile
- Duration & circumstances of the infertility
- Routine gynaecological history
- General & gynaecological examination to establish whether the woman’s genital tract is entirely normal
- Cause of infertility may not be obvious from clinical assessment
Investigations
- HIV test – a positive test does not prevent infertility treatment
- Semen analysis (write a request to Ampath/Lancet) – many men will decline to do. Normal values (WHO): Vol - 1.5ml or more; pH > or equal to 7.2; sperm concentration 15 million/ml or more; total motility 40% or more; progressive motility 32% or more; morphology 4% or more normal (strict criteria – Tygerburg); vitality 58% or more; WBC < 1 million/ml
- Pelvic sonar
- Hysterosalpingogram
- Laparoscopy & dye test (with adhesiolysis if appropriate)
- Day 21 Progesterone level (though a regularly menstrual individual IS ovulatory)
- Endocrine tests as for PCOS if indicated (above)
Management
- Refer patients with anovulation to a consultant or specialist clinic if available; weight loss is effective if appropriate. Clomiphene can be prescribed, with counselling, with an outside script, or metformin, or ovarian drilling if resistant. Some units may offer gonadotrophin stimulation (or not)
- Well-chosen patients with fibroids may benefit from myomectomy or embolization (UAE), or High Intensity Focused Ultrasound (HIFU)
- Advise on lifestyle – avoidance of smoking & alcohol, moderate exercise
- Advise on coital technique & timing around ovulation – fertility maximal either side of Day 14 in a regular cycle
- Patients with tubal factor gain some advantage by laparoscopic surgery/ salpingostomy/ adhesiolysis
- Patients with tubal factor / male factor / unexplained infertility cannot at the moment be offered assisted reproduction, IVF/ICSI (intracytoplasmic sperm injection), in Johannesburg public hospitals. This may change. For male factor ICSI is the only significant treatment though intra-uterine insemination & donor sperm may be considered
- Counsel carefully about cause & ideal management
- Discuss whether the couple can afford private infertility care
- Be honest & sympathetic. Mention alternatives, e.g. adoption
- Do not exclude all hope: some couples will achieve pregnancy spontaneously
- Do not bring patients back repeatedly if nothing further can be done