Makindo Medical Notes

Infertility is a common and distressing problem, affecting up to 1 in 7 couples. It can result from female factors, male factors, or both, and often has significant psychological and social consequences. A structured approach is essential, focusing on history, examination, investigations, and appropriate management.

📖 About Infertility

• Definition: Failure to conceive after 12 months of regular, unprotected intercourse.
• Primary infertility: No previous pregnancy.
• Secondary infertility: Failure to conceive after a previous conception (live birth, miscarriage, ectopic, or termination).
• Has profound emotional and social impact on couples.

⚠️ Risk Factors

• 👩 Female: Age >35, endometriosis, PCOS, PID, previous pelvic surgery.
• 👨 Male: Age >40, varicocele, orchitis, undescended testes, chemotherapy, lifestyle toxins.
• 🍷 Lifestyle: Smoking, alcohol, obesity, poor diet, recreational drugs.
• 🩺 Medical: Diabetes, thyroid disease, autoimmune disorders.

🔎 Causes of Infertility

Category	Examples	Notes
👩 Female – Ovulatory	PCOS, hypothalamic dysfunction, hyperprolactinaemia, premature ovarian insufficiency	Irregular cycles, anovulation
👩 Female – Tubal/Uterine	PID, tubal damage, adhesions, fibroids, endometriosis	Blockage or poor implantation
👨 Male	Low sperm count, poor motility, abnormal morphology, genetic (Y microdeletion, Klinefelter)	Semen analysis abnormal
🔍 Unexplained	No identifiable cause after full evaluation	~25% of cases

🩺 Clinical Assessment

• 📝 History: Age, duration of infertility, menstrual cycles, coital frequency, contraception, STIs, systemic illness, medications.
• 🧑‍⚕️ Exam (Women): BMI, hirsutism (PCOS), pelvic exam for masses or tenderness.
• 🧑‍⚕️ Exam (Men): Testicular volume, varicocele, signs of hypogonadism.
• 💔 Consider psychosocial impact and relationship strain.

🧪 Investigations

• 👩 Women: – Mid-luteal progesterone (day 21 if 28-day cycle). – LH, FSH, prolactin, thyroid function, androgens. – TVUSS (PCOS, ovarian reserve, uterine pathology). – HSG or HyCoSy (tubal patency). – Laparoscopy if endometriosis suspected.
• 👨 Men: – Semen analysis (2–3 samples, ≥3 months apart). – Hormones: LH, FSH, testosterone. – Karyotype/genetic testing in azoospermia/severe oligospermia. – Scrotal ultrasound if varicocele suspected.
• 🧬 Couple: Screen for STIs, HIV, hepatitis B/C before ART.

💊 Management

• 🌱 Lifestyle: Weight optimisation, stop smoking, reduce alcohol, balanced diet, folic acid for women.
• 💊 Medical: – Ovulation induction: clomiphene, letrozole, or gonadotropins. – Metformin in PCOS (insulin resistance).
• 🔧 Surgical: – Laparoscopic treatment of endometriosis. – Tuboplasty for blocked tubes. – Varicocele repair in selected men.
• 🧪 Assisted Reproductive Techniques (ART): – IVF (in vitro fertilisation). – ICSI (intracytoplasmic sperm injection). – Intrauterine insemination (IUI). – Donor gametes or surrogacy if needed.
• 🧠 Psychological support: Counselling, support groups for emotional wellbeing.

📈 Prognosis

• 💊 Ovulatory disorders: Good response to induction therapy.
• 🧬 Male factor infertility: Excellent results with ICSI.
• 🔧 Tubal disease: Variable, improved with IVF.
• 🌍 Unexplained infertility: Many conceive spontaneously or with ART.

📚 References

• RCOG Green-top Guideline No. 12: Fertility Problems – Investigation and Management.
• ASRM Committee Opinion: Diagnostic Evaluation of the Infertile Couple, Fertil Steril. 2021.
• WHO. Infertility definitions and global estimates. 2020.