Makindo Medical Notes

🌸 Causes of Subfertility in Women – Initial Assessment

• ⏳ Duration of Infertility: Defined as no conception after 12 months of unprotected intercourse.
• ❤️ Sexual History: Frequency, timing, and issues such as dyspareunia or male sexual dysfunction.
• 🧷 Contraception History: Previous contraceptive use, duration, and time since stopping.
• 🤰 Pregnancy History: Past pregnancies, miscarriages, or ectopics provide insight into fertility potential.
• 🩸 Menstrual History: Cycle length, regularity, ovulation signs, dysmenorrhea.
• 🩺 Medical History: PCOS, thyroid disorders, diabetes, endometriosis, pelvic inflammatory disease.
• 👪 Family History: Premature ovarian insufficiency, genetic conditions, recurrent miscarriages.
• 🍷 Lifestyle Factors: Smoking, alcohol, obesity, drug use, stress – all reduce fertility potential.

🔎 Physical Examination

• 📏 General Exam: BMI, acne, hirsutism, signs of androgen excess (PCOS).
• 🩻 Pelvic Exam: Fibroids, adnexal masses, tenderness suggesting PID or endometriosis.
• 🦋 Thyroid Exam: Goitre or nodules may point to thyroid dysfunction.

🧪 Basic Investigations

• 🌡️ Ovulation Testing: Day 21 progesterone, basal body temperature, LH kits.
• 🦋 Thyroid Function: Hypo/hyperthyroidism can disrupt cycles.
• 🍼 Prolactin: Hyperprolactinaemia suppresses ovulation.
• 🥚 Ovarian Reserve Tests: Day 3 FSH/estradiol, AMH, antral follicle count (US).
• 🖥️ Pelvic Ultrasound: Detects PCOS, fibroids, endometriomas.
• 🩻 Hysterosalpingography (HSG): Tubal patency + uterine cavity evaluation.

🔬 Further Investigations

• 📹 Laparoscopy: Gold standard for diagnosing endometriosis or adhesions.
• 🔎 Hysteroscopy: Detects and treats intrauterine anomalies (polyps, septa, submucous fibroids).

💊 Treatment Approaches

• 🌿 Lifestyle: Weight optimisation, smoking/alcohol cessation, stress reduction.
• 📅 Timed Intercourse: During fertile window (day 12–16 in a 28-day cycle).
• 💊 Ovulation Induction: Clomiphene citrate, letrozole, or gonadotropins.
• 🔧 Surgery: Myomectomy, endometriosis resection, tubal microsurgery.
• 🧬 ART:
  • 🤱 IUI: Washed sperm placed directly into the uterus.
  • 👶 IVF: Egg fertilised in vitro, embryo transferred to uterus.
  • 💉 ICSI: Single sperm injected into egg – used for severe male factor infertility.

🧠 Psychological and Emotional Support

• 🗣️ Counselling: For stress, depression, relationship strain.
• 🤝 Support Groups: Provide shared experiences and coping strategies.

📩 Referral

• Refer to fertility specialist if no conception after first-line management, or earlier if woman is >35 or has known risk factors.

⚠️ Major Causes of Subfertility in Women

• 🌀 Ovulatory Disorders (e.g., PCOS, anovulation):
  • Dx: Irregular cycles, hormonal assays, US polycystic ovaries.
  • Tx: Weight loss, ovulation induction (clomiphene, letrozole), IVF if refractory.
• 🌹 Endometriosis:
  • Dx: Dysmenorrhea, dyspareunia, chronic pelvic pain, US (endometriomas), laparoscopy.
  • Tx: Laparoscopic excision, hormonal suppression, IVF for advanced cases.
• 🚧 Tubal Factor (blocked/damaged tubes):
  • Dx: HSG, laparoscopy.
  • Tx: Tubal surgery in selected cases, IVF is often preferred.
• 🏛️ Uterine Factors (fibroids, anomalies):
  • Dx: US, hysteroscopy.
  • Tx: Myomectomy, hysteroscopic septum/polyp removal, IVF if persistent.
• ⏳ Premature Ovarian Insufficiency:
  • Dx: High FSH, low estradiol, AMH ↓, karyotype if <40 yrs.
  • Tx: HRT for health; pregnancy possible with donor eggs + IVF.

💡 Exam Tip: Always assess both partners in infertility. In OSCEs, structure your approach: 🧩 History → 🔎 Exam → 🧪 Investigations → 💊 Management → 🧠 Psychosocial support → 📩 Referral.