Infertility

  • Unable to become pregnant after 12 months of regular unprotected sex or to carry pregnancy to live birth. May be primary infertility (never pregnant) or secondary infertility (pregnant in past)

  • Aboriginal traditional beliefs about conception and childbirth are spiritual and relate to the land, Aboriginal cultural stories and Aboriginal Lore. Woman and her partner may hold beliefs about infertility that are strictly traditional, a mixture of Aboriginal and western scientific beliefs or very western. Personal and cultural differences influence the approach to discussions about infertility and investigation of possible causes
  • Woman and her partner both need to be assessed. Explain that assessment involves asking personal, often embarrassing questions. Check if issues should be discussed together or separately. May be better to refer male partner’s to a male health staff member. Important to talk about how pregnancy happens (eg conception) and possible causes of infertility. Treatment can be difficult, expensive, involve travel to a major centre and is not always successful
Causes

Problem with reproductive system in man or woman or both. Often more than one cause

Common causes

  • Woman
    • Hormonal problem — Polycystic Ovary Syndrome (PCOS) or not ovulating regularly
    • Damaged or blocked fallopian tubes — due to Pelvic Inflammatory Disease ( PID), endometriosis
    • Medical problems — diabetes, thyroid disease, kidney disease, overweight, underweight, smoking, older age
  • Man
    • Hormonal problem
    • Blocked tubes
    • Not enough healthy sperm

Initial presentation

Many women present worried about not being able to fall pregnant. Only some need investigation of infertility

  • Talk with woman about infertility even if couple trying to get pregnant for less than 12 months
  • Do Adult Health Check
  • If checks normal give reassurance and education about getting pregnant
    • Talk about healthy lifestyle, losing weight if needed, avoiding smoking and alcohol, taking supplements
    • See her again if not pregnant after 12 months of trying
  • Medical consult for investigation of infertility if
    • Has already been trying for 12 months
    • Checks not normal — history of PID, irregular periods
    • Ongoing medical conditions — PCOS, RHD, SLE
    • Woman 35 years or over

Investigation of infertility

Ask and check file notes 

  • How long she has been trying to get pregnant
  • Menstrual history — last menstrual period, how often, how long, how much blood, pain with periods, age when periods started, ovulation pain, recent changes in periods
  • Fertility and obstetric history — pregnancies with this partner, children from other relationships, previous investigation or treatment for infertility
  • If previous pregnancies — any complications, outcomes
  • Sexual history (current and previous relationships) — how often having sex, timing of sex in relation to ovulation (ovulation usually occurs 2 weeks before period), technique (full penetration), does partner ejaculate, pain with sex, lubricants used and any problems
  • Gynaecological history — abnormal cervical screening results, infections (eg STI, PID, endometritis)
  • Contraception — all methods ever used and any problems
  • Symptoms — vaginal discharge, pelvic pain, tiredness, recent weight loss or gain, abnormal hair growth, urine problems, bowel problems, milk or discharge from nipples, headaches, visual problems
  • Substance use — smoking, alcohol, other substances
  • Medical problems — diabetes, kidney disease, high BP, thyroid problems, heart problems
  • Operations —  hysterectomy, tubal ligation, cone biopsy, termination of pregnancy, caesarean section
  • Medicines — review, consider how they may affect pregnancy. Medical consult if not sure
  • Psychological history — mood, anxiety, relationship problems, feelings about infertility and parenthood, feelings about sex, level of motivation for investigating infertility

Check

  • Adult health check, if not already done
  • BP, BMI, waist circumference
  • Urine — collect mid-stream urine
    • U/A
    • Urine pregnancy test
  • Test/s for diabetes, if not already done
  • Signs of PCOS
    • Acne
    • Dark patches of skin at creases or folds (eg neck, armpit) — acanthosis nigricans
    • Hair distribution — look for male pattern (eg beard, moustache)
    • Obesity
  • Check arm's for ENG-implant- look for scars, palpate
  • Thyroid check — any enlargement or nodules
  • Chest and heart sounds — any murmurs
  • Signs of high prolactin — galactorrhoea (milk discharge from breasts)
  • Abdomen — scars, tenderness, masses
  • Genital exam, speculum exam if skilled — check for IUD strings
  • Bimanual exam if skilled — signs of PID, masses

Do

Talk with woman about

  • Managing any immediate problems
  • Healthy lifestyle including weight loss if needed, reducing alcohol, stopping smoking and other drugs, taking pregnancy supplements
  • Keeping record of periods (menstrual history) — ask woman to record days that she has bleeding, using either a calendar or phone app OR ask her to contact clinic when her period starts
  • Returning for her results, more blood tests if needed
  • Medical consult about history and findings, to develop plan of management
    • Doctor may ask you to take initial blood tests

Initial tests

Take blood, urine and swabs needed for

Doctor may request hormone tests

  • Take blood for
    • Serum FSH, LH, oestradiol (E2), prolactin, thyroid function tests
    • If excessive body hair or irregular periods — add tests for free androgen index (FAI), free testosterone, sex hormone binding globulin (SHBG)
    • May need additional tests to exclude other conditions similar to PCOS
  • If diagnosis uncertain — some blood tests may need to be repeated on day 2–3 of womans menstrual cycle
  • If regular menstrual cycle — serum progesterone to check ovulation
    • Do test 7 days before next period due — day 21 for a 28-day cycle, day 28 for a 35-day cycle
    • If results inconclusive — consider repeating 1 week later
  • Write date of last menstrual period (LMP) on request form so doctor can interpret results correctly

Follow-up

  • Medical consult about results and updating management plan
  • Talk with woman about
    • Test results
    • Treatment or further tests needed
    • Fertile times in menstrual cycle — Figure 6.17
    • Times when intercourse most likely to result in pregnancy
    • Keeping menstrual history
    • Ask woman to record days that she has bleeding, using calendar or phone app OR ask her to contact clinic when her period starts
    • Whether to continue with investigations

Figure 6.17   

Further management

Woman

  • Check that she wants to go ahead with specialist referral and management
  • If so — medical consult
    • If PCOS — doctor may suggest metformin
    • Doctor will refer to gynaecologist
  • Advise woman
    • She may see male gynaecologist
    • Ultrasound may be done — may be transvaginal
  • After gynaecology appointment — may need procedure to see if problem with uterus, tubes blocked
    • X-ray with radiopaque dye (hysterosalpingogram)
    • Laparoscopy and dye test
    • Ultrasound test for tubes (hysterosalpingo contrast ultrasonography)
  • May start on medicine to help her ovulate (eg metformin, clomiphene, letrozole)
    • ​Refer to gynaecologist for specific advice on clomiphene protocol
  • ​Check with service provider about financial support for travel, and whether dependent on primary or secondary infertility

Male Partner

  • May want to see male clinician
  • Needs thorough history and examination including Adult Health Check, STI check, immunisations
  • Key questions
    • Had children previously
    • History of testicular trauma or operations
    • Substance use, general medical health
  • Semen analysis — essential even if man has fathered a pregnancy in the past
    • Specimen needs to get to laboratory within 1 hour of collection
  • After these tests, reason for infertility may be diagnosed
    • Treatment depends on cause — may involve medical treatment, surgery, assisted reproduction techniques (ART)

Assisted reproduction

  • Some couples need ART (eg in-vitro fertilisation (IVF))
    • Involves trips to specialist service in major centre, financial and psychological costs to couple
    • Chances of successful pregnancy in each ART cycle are about 1 in 4. Chances decrease as woman gets older — see supporting resources
    • Need referral from doctor
  • Check cost of treatment with service. May be lower if both have Health Care card, but still high. All costs need to be paid in advance before any Medicare refund

Supporting resources