The subfertile couple

Probability diagnosis

The couple:

• ageing

• sexual technique incl. dyspareunia

Female factors approx. (40%):

• ovulation disorders e.g. ovarian failure, PCOS

• other causes amenorrhea or hypomenorrhea

• tubal disease e.g. endometriosis

Male factors (approx. 40%):

• defective sperm

• anti-sperm agents e.g. cytotoxic, anabolic steroids

Serious disorders not to be missed

Infection:

• STIs → tubal or epididymal blockage

• Pelvic inflammatory disease

• Endometrial TB

Tumours:

• Uterine fibroids/cancer

• Pituitary or adrenocortical

Other:

• Systemic illness

• Cervical stenosis

• Diet/obesity

Pitfalls (often missed)

Unreceptive cervical mucus

Rarities:

• Anatomical congenital disorders e.g. uterine, Fallopian

• Chromosomal abnormalities e.g. Klinefelter syndrome, Turner syndrome

Masquerades checklist

Depression incl. drugs

Diabetes

Drugs: various

Thyroid/other endocrine: several incl. hyper/hypothyroid, prolactinaemia

Spinal dysfunction

Is the patient trying to tell me something?

Consider psychosexual dysfunction incl. technique

NB: unexplained 20–25%

Key history

In men: sexual function, past history incl. testicular problems e.g. mumps orchitis, undescended testes; medical problems e.g. diabetes, STIs, genitourinary surgery; occupational e.g. exposure to heat, pesticides; drugs e.g. chemotherapy, illicit agents, alcohol, smoking, antihypertensives. Frequency and timing of intercourse (both). In women: past history incl. previous fertility, obstetric, menstrual, STIs and PID, genitourinary surgery and abdominal surgery esp. appendicitis, peritonitis, abortion, IUCD use, body weight, drugs e.g. smoking, alcohol, OCP, anabolic steroids. Symptoms of ovulation and endometriosis

Key examination

Both: body habitus, general health, secondary sex characteristics, urinalysis.

Men: external genitalia including testes (normal range 15–35 ml) and penis, PR.

Women: genitalia and breasts, thyroid status, vaginal and pelvic examination.

Key investigations

Men:

• semen analysis

Consider:

• FSH & LH

• testosterone

• sperm function tests e.g. antibodies

• testicular ultrasound

• chromosomal analysis

Women:

• basal body temperature chart and cervical mucus diary

• s. progesterone (mid luteal)

• anti-Mullerian hormone

• rubella status

• transvaginal ultrasound

Consider:

• thyroid status

• s. prolactin

• FSH and LH

• coeliac antibodies

• chlamydia test

• hysterogram

• hysteroscopy/laparoscopy

• CT pituitary fossa

• reproductive gene screening e.g. cystic fibrosis, fragile X