1. The document discusses definitions and background information about infertility, including definitions of subfertility and infertility. It provides data on typical conception rates over 1-2 years and categories of subfertility. 2. It examines factors that can influence fertility rates, including age, previous pregnancies, BMI, smoking status, caffeine intake, and recreational drug use. It also discusses the impact that subfertility can have psychologically and socially. 3. The document outlines the typical process for initial assessment and investigations for couples experiencing fertility issues, including baseline tests, ultrasound, HSG, semen analysis, and potential referrals to secondary care for additional

1. Infertility for Primary Care
Luciano G. Nardo MD MRCOG
Visiting Professor, Manchester Metropolitan University
Board & Clinical Director, Reproductive Health Group
Consultant Gynaecologist
Subspecialist in Reproductive Medicine & Surgery
Centre for Reproductive Health, Daresbury Park, UK

2. Subfertility - A long Journey

3. Infertility – Definitions & Background
• Subfertility: is a failure to conceive after one year of unprotected regular
sexual intercourse.
• Fertility: Ability to conceive
• Fecundity: Ability to carry to delivery
• Primary / Secondary
• 84% of couple will conceive by 1 year
• 92% by 2 years
• 8% true sub-fertility
• 4% Infertility
• With unexplained sub-fertility of more than three years, the chances of
conception occurring are about 1-3% each cycle

4. MFR 6/12 12/12 24/12 60/12
Superfertile 60% 100% - - -
Normally fertile 20% 74% 93% 100% -
Moderately subfertile 5% 26% 46% 71% 95%
Severely subfertile 1% 6% 11% 21% 45%
Infertile 0% 0% 0% 0% 0%
Cumulative pregnancy rate after
Model of cumulative spontaneous pregnancy rates
according to duration of infertility
Evers, Lancet 2002

5. Factors influencing fertility
Cumulative conception rate in the first year of trying

6. Factors influencing fertility
• Increased chance of conception
- Woman age < 30 years
- Previous pregnancy
- < 3 years sub-fertility
- Well timed & regular coitus Dunson et al
(2002)
- Woman’s BMI 20-30
- Both partners non smokers
- Caffeine intake < 2 cups of coffee daily
- No use of recreational drugs
• Reduced chance of conception
- Women aged > 35 years
- No previous pregnancy
- > 3 years sub-fertility
- Infrequent coitus
- Woman’s BMI < 20 or > 30
- One or both partners smoke
- Caffeine intake > 2 cups of
coffee daily
- Regular use of recreational drugs

7. The impact of sub-fertility
• Stress
• Sense of failure
• Relationship difficulties
• Social, Psychological & Economic effects

8. Preconception advice -1-
 Smoking &
Recreational drugs
- Advice
 Folic Acid supplements
- 0.4 mg routine
- 5 mg if epilepsy or history of
NTDs, PCOS. DM
 Pre-existing medical
problems
- Stabilise medical conditions
- Ensure safe drug treatment
 Weight
- Check BMI
- Advice and refer

9. Preconception advice -2-
• Virology / Bacteriology
Screening
- Rubella / Varicella immunity
- HIV, Hep B & C
- Chlamydia
• Prenatal diagnosis
- Tell older women about
options
- Any specific disorders
 Timing of intercourse
- Advice
 Factors affecting sub-
fertility
- Discuss any factors in
either partner’s history or
examination that might
warrant early referral for
specialist infertility advice

10. Major Causes of sub-fertility
1. Ovulatory
2. Male factor
3. Tubal / Pelvic
4. Unexplained
%
Anovularory Tubal Male Unexplained/Undiagnosed

11. Infertility affects 1 in 6 heterosexual couples in the UK
Unexplained infertility 25%
Ovulation disorders 25%
Tubal damage 20%
Male infertility 30%
Uterine disorders 10%
Causes of infertility

12. Making a diagnosis
• Factors that may warrant early referral or investigation
• Initial investigations that can be done in primary care
• Investigations in secondary care

13. Timing of initial assessment for couples with
fertility problems
After 1 year of regular unprotected sexual intercourse
Earlier, if: Amenorrhoea or oligo-menorrhoea
Pelvic inflammatory disease
Undescended testes
Woman’s age ≥35 years
Known reason for infertility
Testicular accident
Cancer
Chronic viral infections

14. Investigations
Assessment of ovarian function
Assessment of tubal patency
Assessment of sperm function
Assessment of uterine abnormalities
Screening for Chlamydia trachomatis
Rubella immunity

15. Baseline Investigations
• Day 2/3 FSH =
• Day 2/3 LH =
• Day 2/3 Oestradiol =
• Mid-luteal phase serum Progesterone =
• Anti-Mullerian Hormone
• Prolactin (if menstrual abnormalities) =
• Thyroid Function Tests TSH = FT4=
• Androgen profile (if menstrual abnormalities) =
• HVS =
• ECS =
• Chlamydia =
• Rubella Status = Immune / Non immune
• Folic Acid Advised = Yes / No
• Cervical smear: Date Result:
Semen Analysis
Previous reversal of
vasectomy: Yes/No
Volume:
Density (million/ml) =
Motility (%) = A,B,C
Normal Morphology (%) =
Male

17. Markers of Fertility potential
and response to treatment
Marker High Responders Low Responders
Total Antral follicle count >16 <4
Anti-Mullerian Hormone (AMH) ≥ 25.0 pmol/l ≤ 5.4 pmol/l
Follicle-stimulating Hormone (FSH) < 4 IU/l > 8.9 IU/l

18. Secondary Care Investigations -1-
Pelvic ultrasound

19. Secondary Care Investigations -2-
HyCoSy - (Hysterosalpingo-contrast sonography)
28/11/2015

20. Secondary Care Investigations -3-
HSG (Hysterosalpingography)

21. Secondary Care Investigations -4-
Laparoscopy
Normal pelvis

22. Secondary Care Investigations -5-
Diagnostic laparoscopy and methylene blue dye test

23. Secondary Care Investigations -6-
Diagnostic laparoscopy

24. Secondary Care Investigations -7-
Hysteroscopy

25. Primary / Secondary Care Investigations -8-
Seminal analysis

26. Normal Semen Parameters
WHO 2010
Variable Normal values
Volume ≥ 1.5 ml
pH ≥ 7.2
Concentration ≥ 15 x 106 per ml
Total number ≥ 39 x 106 per ejaculate
Progressive motility ≥ 32% grades a + b
Total motility ≥ 40% grades a + b + c
Morphology ≥ 4% normal forms
viability 58% alive
White blood cells < 1.0 x 106 per ml
Sperm antibodies ≤ 50% of coated sperm

27. Secondary Care Investigations -8-
Investigating azoospermia, by site of abnormality
Investigating azoospermia, by site of abnormality
Obstructive Non-obstructive
Post-testicular Testicular Hypothalamic-pituitary
Congenital causes Vasal aplasia, cystic fibrosis,
mullerian cysts
Genetic causes,
cryptorchidism, anorchia
Kallman’s syndrome, isolate FSH
deficiency
Acquired causes Gonorrhoea, Chlamydia,
tuberculosis, prostatitis,
vasectomy
Radiotherapy,
chemotherapy, orchitis,
trauma, torsion
Craniopharyngioma, pituitary tumour,
pituitary ablation, anabolic
steroids
Testicular size Normal Small, atrophic Small, prepubertal
FSH Normal Raised Low
Testosterone Normal Low Low

28. Prevention of Infertility - Male
• Environmental – reduce oestrogenic pollutant
– protect workers in chemical industries
• Undescended testis – early orchidopexy
• Surgery to testis – avoid injury to vas, testicular vessels …
• Varicocoele – ligation ?

29. Prevention of Infertility - Female
• Avoid unwanted pregnancies & TOPs
• Care of pelvic organs (early recognition of abdominal sepsis, care at
surgery)

30. Prevention of Infertility - Both
• Avoid STDs – barrier methods of contraception
• Don’t delay childbearing to late 30’s and 40’s
• Storage of sperm / oocytes (ovarian tissue) before
chemo / radiotherapy

31. Trends in Fertility Treatments
• Transferring Fewer Embryos
• Egg bank
• Egg freezing/storage
• Acupuncture

32. Make the journey shorter and brighter

33. Scenario 1
11 months secondary couple subfertility
Female partner: 27 years old
BMI: 35 kg/m2
Periods: irregular
2 previous first-trimester miscarriages (with this partner)
Gyn history: nil of note
Male partner: 27 years old
No medical/surgical history of note
Would you
investigate this
couple?

34. Scenario 2
10 months primary couple subfertility
Female partner: 36 years old
BMI: 25 kg/m2
No previous pregnancies
Periods: regular
Gyn history: dysmenorrhoea and deep dyspareunia
Previous form of contraception: IUCD (3 years)
Male partner: 37 years old
2 children from a previous relationship
Would you
investigate this
couple?

35. Scenario 3
Planning to conceive
Female partner: 30 years old
BMI: 26.5 kg/m2
1 TOP (with different partner)
Periods: regular
Gyn history: nil of note
Male partner: 29 years old
Klinefelter’s syndrome (47XXY)
Would you
investigate this
couple?