QuestionSBA
QuestionChoice
A pelvic ultrasound can be helpful in assessing the structural integrity of the reproductive organs, including the uterus and ovaries. However, since the woman has normal FSH and progesterone levels, indicating normal ovulatory function, and there is no indication of structural abnormalities from the history provided, a pelvic ultrasound is not the immediate next step. A semen analysis would be prioritised first.
10015722
b
Pelvic ultrasound
QuestionChoice
Whilst pregnancy is likely to happen within 2 years of unprotected intercourse, it would be inappropriate to not investigate the couple further at this stage.
10015723
c
Reassure them that pregnancy is likely to take place in the next six months
QuestionChoice
NICE recommend investigations (and consideration for onward referral) for couples who have tried to conceive unsucessfully for one year. The woman has already had first line investigations (mid-luteal phase progesterone). The man also requires investigation with semen analysis. Both partners should be screened for STIs (especially Chlamydia).
10015721
a
Semen analysis
QuestionChoice
Invasive tests may be required in the future, however, this would not be the next most appropriate step.
10015725
e
Salpingogram
QuestionChoice
While a referral to a fertility specialist is often warranted in cases of prolonged infertility, it usually occurs after completing basic investigations, including semen analysis and assessments of ovulation. Once these preliminary tests are done, if an issue is identified or if the results are inconclusive, a referral would be appropriate. Therefore, semen analysis is the step that should precede a specialist referral.
10015724
d
Referral to a fertility clinic
QuestionComment
Hi Resit Merchant
52160
User
subscriber
Anishocoria
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)
929
3506
Infertility
Topic
60
General Practice
15688
Infertile couples who have tried unsuccessfully to conceive for one year should undergo semen analysis as part of their investigation, alongside screening for sexually transmitted infections for both partners.
Presentation
519
Subfertility
UkmlaTopic
12
General practice and primary healthcare
Presentation
520
Subfertility
UkmlaTopic
18
Obstetrics and gynaecology
Presentation
521
Subfertility
UkmlaTopic
25
Surgery
A 24-year-old man and 23-year-old woman with no medical history visit their GP with concerns of infertility. They have been trying to conceive for 1.5 years. A private blood test reveals that the woman has a normal FSH level and day 21 progesterone.

What is the next most appropriate step in management?
a