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Evaluation of the Infertile Couple
Appropriately directed history, examination and investigations are important.
Note should be made of the duration of infertility, previous pregnancies (for either partner), previous infertility and treatments. Especially important is menstrual history, seeking symptoms of ovulation (e.g. midcycle mucous or pain) and premenstrual symptoms. If the patient has irregular or no menses, search for clues to causes of anovulation (e.g. nipple discharge, excessive weight change, hirsutism, acne, stress). Ask about regularity and timing of intercourse, and difficulties with it. Seek clues to causes of tubal disease (e.g. previous PID, IUCD use or appendicitis).
Also important to discuss are the patient's reasons for seeking treatment (e.g. personal desire for a baby, family or racial expectations or peer pressure). This may lead to a discussion about coping with their infertility and what their expectations are of treatment.
A well woman check including breast examination, BP and pap smear if due are appropriate. If indicated abdominal, and pelvic examination can be helpful but pelvic ultrasound will provide much of this information.
In the male, if the semen analysis is significantly abnormal, the testes should be examined to estimate testicular volume and exclude scrotal lumps/tumours.
The family practitioner may perform some of the basic investigations for the infertile couple. These include:
1. Semen analysis/sperm count. Repeat if abnormal as sperm production is dynamic and even fertile men sometimes have a “bad month”. If possible a specialist andrology lab at an IVF clinic will give you a more accurate result.
2. Confirm ovulation (or diagnose anovulation):
* Mid-Luteal serum progesterone - approx. 1 week before expected day of next menses. If someone has a 28 day cycle then day 21 is appropriate. If someone has a 35 day cycle then day 28 is appropriate.
* If anovulation is suspected check serum prolactin, LH and FSH, TSH, SHBG, testosterone and free androgen index or free testosterone. Consideration should be made of glucose and insulin testing if patient is suspected of having PCOS.
3. Chlamydial PCR testing
4. Antenatal testing & immunisation
• Check rubella immunity and immunise if necessary. Pregnancy should be avoided for 30 days after immunisation as it is a live virus.
• Consideration should also be given to doing a full antenatal screen to rule out syphilis, hepatitis, HIV, etc.
• Varicella vaccination may also be considered if the patient is non-immune.
• Flu and whooping cough vaccination may also be appropriate.
5. Trans-vaginal pelvic ultrasound can exclude significant pelvic & uterine pathology especially if done in the follicular phase of the cycle (first 10 days). It can not however diagnose tubal blockages or mild endometriosis.
It is appropriate to vary the above where circumstances dictate eg known blocked tubes or previous vasectomy and refer early.
• Folate and iodine should be taken as supplements by the female partner who is attempting pregnancy.
• Smoking in both male and female partners reduces the likelihood of pregnancy as well as increasing the risks to the pregnancy. Smokers have half the likelihood of pregnancy with IVF treatment versus non-smokers.
• Patients who are overweight also reduce their likelihood of pregnancy and increase their chances of miscarriage. Weight loss of even 5-10kg has been shown to help pregnancy to occur in women with PCOS.
• In women who are significantly underweight (BMI <18) considerations should be given to weight gain to improve ovulation and pregnancy outcomes.
Couples should be advised to have regular intercourse in the days leading up to and around ovulation. Some women have signs of ovulation including mucous changes and midcycle pain that may indicate when ovulation is occurring. Generally in someone with a regular menstrual cycle ovulation occurs 14 days prior to the onset of menses and the most fertile period of the cycle starts 4 days prior and up to ovulation. For example in someone with a 30 day cycle ovulation occurs roughly on day 16 and sex from cycle day 12-16 would be appropriate. Sperm has the capacity to remain viable within the female genital tract for up to 48-72 hours and hence sex every two days is all that is required. More frequent sex if the couple desires will not reduce the chances of conception.
In couples not capable of sex more than once a week ovulation prediction testing may be useful. These tests can be purchased online, at supermarkets and chemists. They measure the hormone LH in the urine and when the LH surge is seen ovulation should occur in the next 1-2 days and hence sex should occur now. LH testing can be expensive and if no surge is seen it does NOT mean ovulation did not occur. In couples capable of regular sexual activity I do not think they contribute a great deal. The saliva test kits also available are completely inaccurate and not at all recommended. Basal body temperature testing is not helpful as it does