This document defines infertility as failure to conceive within one year of regular unprotected sex. It discusses primary and secondary infertility and natural conception rates. The causes of infertility are outlined for both female and male factors. Investigation methods are described including indirect tests like hormone levels and direct tests like laparoscopy. Management is discussed for primary care including lifestyle changes and preconception advice. Secondary care management depends on the etiology and may include medications, surgery, and assisted reproduction techniques.

2. DEFINITION
Infertility is defined as a failure to
conceive within one or more years
of regular unprotected coitus

3. TYPES
 PRIMARY
 SECONDARY

4. Natural conception rates:
 80% of couples will be pregnant after 12
cycles.
 50% of remaining will conceive during a
2nd year ( hence cumulative rate 90%)
 50% in the following 4 years.

5. CAUSES

6. FEMALE FACTOR
 GENETICS &IMMUNOL
 IATROGENIC FACTOR
 OVARIAN FACTOR
 TUBAL AND PERITONEAL FACTORS
 UTERINE FACTOR
 CERVICAL FACTOR
 VAGINAL FACTOR
 COMBINED FACTOR

7. INVESTIGATION

8. FEMALE INVESTIGATION
 INDIRECT
MENSTRUAL HISTORY
BBT
HORMONEAL ESTIMATION
CERVICAL & VAGINAL CYTOLOGY
ENDOMETRIAL BIOPSY
SONOGRAPHY
 DIRECT
RUBIN TEST
HYSEROSALPINGOGRAPHY
LAPROSCOPY

9. MENSTRUAL
HISTORY
BBT
CERVICAL
VAGINAL
CYTOLOGY
HORMONE
ESTIMATION
ENDOMETRIAL
BIOPSY
SONOGRAPHY
INDIERCT

10. LAROSCOPY
HSG
RUBIN TEST
DIRECT

11. Management in primary care
Lifestyle changes
- Weight reduction,
BMI 19-29
- Smoking cessation- offer support groups
- Alcohol reduction
<1-2 units/week for women
<3-4 units/week for men
- S I every 2-3 days
- Information about OTC/ recreational drugs

12. Management in primary care
 Pre conceptual advice
- Folic acid supplementation
- Rubella status
- Cervical screening
 Management of erectile dysfunction
- psychosexual couselling
- drugs

13. Management in secondary care
 Depends upon the etiology..

14. Hypogonadotrophic hypogonadism
 Pulsatile GnRH
 Gonadotrophins with LH activity
 Bromocriptine ( for hyperprolactinaemia)

15. Ovarian dysfunction
( hypothalamic dysfunction)
1) Anti- oestrogens eg Clomiphene/ Tamoxifen
- 1st line
- use for atleast 12 months if ovulating
- initiated in secondary care
- under USG guidance ( to adjust dose)
- shared care when dose established
- S/E risk of multiple pregnancy, OHSS

16. 2) Metformin
3) Gonadotrophins
4) Luteal phase support –
- progesterone,
- clomiphene
5) Laparoscopic ovarian drilling

17. Uterine/ tubal factors
 Tubal factors:
- Laparoscopic tubal surgery/ tubal microsurgery
- Salpingography + tubal catheteristion
- Hysteroscopic tubal cannulation
 Uterine factors
- hysteroscopic adhesiolysis
- myomectomy

18. Peritoneal problems (endometriosis)
 Laparoscopic surgical ablation/ resection of
endometriosis + adhesiolysis
 If ovarian endometriomas, laparoscopic cystectomy

19. Assisted reproduction techniques
 Intra uterine insemination (IUI)

20. In vitrio fertilisation

21. SURROGACY

22. THANKS