QuestionSBA
QuestionChoice
This woman has polycystic ovary syndrome (PCOS). PCOS can be diagnosed using the Rotterdam criteria, where two of the following three are present:
 

 - Oligo- or amenorrhoea
 - Clinical or biochemical evidence of hyperandrogenism
 - Polycystic appearance of the ovaries on ultrasound
 

 Although her general practitioner has performed multiple hormone blood tests and ordered an ultrasound scan, these are not necessary to provide a diagnosis. She has evidence of oligomenorrhoea (long, irregular cycles) and clinical evidence of hyperandrogenism (acne, hirsutism).
 

 PCOS does not cause absolute infertility, as often the woman still ovulates, but less frequently. The advice is to refer to the fertility clinic where a couple has been trying to become pregnant for two years.
49802
a
Advise the woman to continue having unprotected intercourse and ask to be referred to the fertility clinic if she has not become pregnant after 1 year in total
QuestionChoice
BMI is calculated as weight (kg)/height m<sup>2</sup>. Her BMI is 24.9 kg/m<sup>2</sup>, just within the normal range. Women with a BMI over 25kg/m<sup>2</sup> may benefit from weight loss to increase the chances of pregnancy.
49803
b
Advise the woman to lose weight
QuestionChoice
Couples trying to conceive should be advised that sexual intercourse every 2 to 3 days optimises the chance of pregnancy.
49806
e
Advise having sexual intercourse daily to increase the chance of conception
QuestionChoice
BMI is calculated as weight (kg)/height m<sup>2</sup>. Her BMI is 24.9 kg/m<sup>2</sup>, just within the normal range. Women with a BMI over 25kg/m<sup>2</sup> may benefit from weight loss to increase the chances of pregnancy.
49805
d
Advise a trial of combined oral contraception to regulate her periods
QuestionChoice
Referral to the fertility clinic is only warranted where the couple have been trying to conceive for two years.
49804
c
Advise the woman's husband to ask for a referral to the fertility clinic for semen analysis
QuestionComment
Could you have not just given us the BMI
52148
User
subscriber
Neutrophillia
Concept
Chapter
# Summary
  
 
Subfertility is defined as the diminished ability of a couple to conceive a child, which may be due to a variety of definable causes or an unexplained failure to conceive over a two-year period. Key signs and symptoms vary based on the underlying cause but generally revolve around the inability to achieve pregnancy despite regular unprotected sexual intercourse. Investigations typically include hormonal studies, semen analysis, and imaging studies. The management of infertility is dependent on the underlying cause and often involves a combination of lifestyle modifications, medical interventions, and assistive reproductive technology. 
  
   
 
# Definition
  
Infertility is the diminished ability of a couple to conceive a child. This may result from a definable cause such as ovulatory, tubal, or sperm problems, or may be an unexplained failure to conceive over a two-year period despite regular (3-4 times a week) unprotected sexual intercourse.
  
 
  
# Epidemiology
  
 
Statistically, a couple stands an 80% chance of conceiving within one year if the woman is younger than 40 years, they do not use contraception, and they have regular intercourse (3-4 times per week). This overall probability increases to 90% if considered over two years.
  
 
# Aetiology

 
Factors affecting natural fertility include:
 
  - Increasing age
  - Obesity
  - Smoking
  - Tight-fitting underwear (males)
  - Excessive alcohol consumption
  - Anabolic steroid use
  - Illicit drug use
  
 

Causes of infertility can be classified into:
  
 
  - **Genetic causes:** This includes Turner's syndrome (XO) and Kleinfelter's syndrome (XXY).
  - **Ovulation/endocrine disorders:** Examples are polycystic ovary syndrome, pituitary tumours, Sheehan's syndrome, hyperprolactinaemia, Cushing's syndrome, and premature ovarian failure.
  - **Tubal abnormalities:** These can be due to congenital anatomical abnormalities or adhesions secondary to pelvic inflammatory disease (often caused by chlamydia or gonorrhoea).
  - **Uterine abnormalities:** These include bicornate uterus, fibroids, and Asherman's syndrome (uterine adhesions).
  - Endometriosis
  - **Cervical abnormalities:** These include cervical damage after biopsy or LLETZ procedure.
  - **Testicular disorders:** Disorders such as cryptorchidism, varicocele, testicular cancer, and congenital testicular defects fall in this category.
  - **Ejaculatory disorders:** These include obstruction of the ejaculatory system and disorders of ejaculation such as retrograde ejaculation and premature ejaculation.
  
 
# Investigations
  
 
Investigations for infertility are divided into those for men and women. 

*For women:*

**Bedside:**
 
- Thorough history, including past medical history, sexual history and details of past pregnancies. 
- Speculum and bimanual examination: To investigate physical anomalies (e.g. large fibroids). 
- STI screen
 
 
**Bloods:**
 
  - Serum progesterone testing (performed 7 days before the end of the menstrual cycle): A rise in progesterone indicates that the corpus luteum has formed and is releasing progesterone due to occurrence of ovulation.
  - Prolactin
  - LH/FSH 
  - Anti-mullerian hormone (AMH): Measure of ovarian reserve
  - TFTs 

 
**Imaging:**
 
- Transvaginal ultrasound scan: To identify any physical anomalies of the uterus, and check antral follicle count (measure of ovarian reserve)
- Hysterosalpingography: Assess tubal patency.
- Laparsocopy and dye: Assess tubal patency in presence of co-morbidities (e.g. PID, ectopic pregnancy, endometriosis). 


*For men:*

**Bedside:**
 
- Thorough history, including past medical history, sexual history and details of past pregnancies. 
- Testicular examination: To investigate visible physical anomalies (e.g. varicocele). 
- Semen analysis: To evaluate sperm count, motility, and morphology. 
 
 
**Bloods:**
 
  - Serum testosterone 
  - LH/FSH 
  - TFTs 
  
 
# Management
  
 
The management of infertility is tailored to the underlying cause but may include:
  
**Conservative:**

  - Weight loss
  - Smoking cessation 
  - Reduction of alcohol intake
  - Stress-reduction strategies

**Medical:**

Medications may be used for ovulation induction, such as: 

  - Clomiphene
  - FSH and LH injections
  - GnRH or DA agonists

  
**Surgical:**
  
  - Assisted reproductive technology, including in vitro fertilisation or intracytoplasmic sperm injection.


In addition to all of the above, if an underlying cause of infertility is found (e.g. fibroids, endometriosis), then those causes should be managed. 


# NICE Guidelines

[Click here for NICE Guidelines on fertility problems](https://www.nice.org.uk/guidance/cg156)

[Click here for NICE Guidelines on infertility](https://cks.nice.org.uk/topics/infertility/)

# References 

[BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/498)

[Fields et al., 2023 - BMJ](https://www.bmj.com/bmj/section-pdf/187753?path=/bmj/346/7896/Practice.full.pdf)
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976
Subfertility
Topic
26
Gynaecology
Advise the woman to continue having unprotected intercourse and ask to be referred to the fertility clinic if she has not become pregnant after 1 year in total
9997
A 26-year-old woman attends her general practitioner with difficulty conceiving. She has been having regular unprotected intercourse with her 27-year-old husband for six months. She has never taken any hormonal contraception. She describes her periods as "a bit irregular" with a 50-75 day cycle.



On examination, she is 170cm tall and weighs 72kg. She has notable facial acne and has dark hair on her chin and around her areola.




Her blood tests results are as follows:


||||
|---------------------------|:-------:|------------------------------|
|Testosterone|1.9 nmol/L|(M) 9.9 - 27.8, (F) 0.2 - 2.9|
|Androstenedione|15.8 nmol/L|1.3 - 5.8|
|Luteinising Hormone|9.1 IU/L|1 - 11 (Luteal)|
|Follicle Stimulating Hormone|5.4 IU/L|2 - 8 (Luteal)|
|LH/FSH ratio|1.7||
|Dehydroepiandrosterone sulfate (DHEAS)|6.7  µmol/L|2.7 – 9.2|



A pelvic ultrasound shows bilateral ovary are enlargement, with multiple peripheral follicles.



What is the most appropriate management?
a