Infertility

Description

General measures

Medicine treatment

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ICD-10 code: N97.0-4/N97.8-9

DESCRIPTION

Inability to conceive after a year of regular sexual intercourse without contraception.

GENERAL MEASURES

• Counselling.
• Lifestyle modification, e.g. weight optimisation, smoking cessation and regular sexual intercourse.

Investigations

• Partner semen analysis.
• Anti-mullerian hormone (AMH) levels to evaluate ovarian reserve (>1.1 ng/ml suggests good ovarian reserve)
• If AMH is unavailable - Mid-luteal (day 21) progesterone assay: > 30 nmol/L suggests adequate ovulation (Specialist indication).
• Laparoscopy and/or hysterosalpingography (Specialist supervision).

MEDICINE TREATMENT

Treat the underlying disease.

For induction of ovulation, in women with confirmed anovulation:

• There are two options available: letrozole or clomifene. 
• Letrozole is likely to result in more pregnancies and sooner pregnancies but both agents are effective.
• Administer letrozole following a spontaneous menses or a medroxyprogesterone acetate withdrawal bleed.
• Letrozole 2.5 mg daily on days 3-7 of the cycle (Specialist only).

LoE: IIb^xviii

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Note:
- Letrozole for ovulation induction is an off-label indication. Counsel patient and obtain patient consent.
- Consider the use of an alternative agent in patients with moderate or severe hepatic disease, porphyria, or osteoporosis.

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If letrozole cannot be used:

• Clomifene, oral, 50 mg daily on days 5–9 of the cycle (Specialist only).
  • Monitor the progress of ovulation.

LoE:IIb^xix

For hyperprolactinaemia after further investigation:
See Prolactinoma.

Click here for the pdf

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Note:
Women should be counselled on the risk of multiple births with ovulation inducing medicines.

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Standard Treatment Guidelines and Essential Medicines List for South Africa Adult Hospital _Chapter 5: Gynaecology; Version 1.0, 2020-4_June 2024