Treatment

Initial evaluation of the Infertile couple

Complete history and physical examination:

The PE Fertility Clinic encourages patients to obtain all previous medical records for treatment related to infertility, hormonal or menstrual disturbances, anovulation, gynaecologic surgery, or pelvic infection. Appropriate medical information should also be gathered on the husband i.e. previous semen analysis and prior hormone tests Particular attention is directed towards a review of medications that may interfere with fertility (i.e. anti hypertensive and non-steroidal anti-inflammatory drugs in males) or those that might be teratogenic (harmful to the foetus).

Semen Analysis:

A semen analysis is the easiest and most cost effective test that a couple can undergo to determine fertility potential. A semen analysis is considered current if it has been obtained within the last 4 months and performed by a reputable laboratory using acceptable criteria. Semen analysis that show abnormal values should be rechecked no sooner than 4 weeks prior to any assisted reproductive treatment. The parameters for a normal semen analysis are as follows:

Motility: > 30%
Forward Progression > 2
Count > 20 million/ml
Antibodies (MAR Test) < 60%
Morphology > 14%

Semen quality can always be improved through lifestyle changes. Smokers should be advised to stop smoking and be placed on antioxidant supplementation (Vitamin C 1gm/day and Vitamin E 400ugm/day as well as folic acid). Men should also not consume more than 4 units of alcohol a week and should be encouraged to eat green leafy vegetables. These lifestyle changes should be undertaken for a minimum of 3 months before a change can be seen in semen quality.

Initial Medical Laboratory Evaluation:

On the 2nd or 3rd day of the menstrual cycle , a basic hormone profile is performed (FSH, LH, Thyroid function, Prolactin), together with a sexually transmitted disease profile (HIV, Hepatitis B, VDRL) and assessment of immunity to German Measles.

Individualised Laboratory Testing:

When clinically indicated, further tests will be performed by the reproductive specialist to diagnose endocrinological abnormalities that may present with signs of virilization, abnormal menstrual cycles or abnormal genital organ anatomy as seen in chromosomal/genetic variants. The most common endocrinopathy seen in the reproductive years is Polycystic Ovarian Syndrome (PCOS), with usually some or all the features of absent or irregular periods; signs of virilization such as acne or hirsutism and abnormal ovaries on ultrasound evaluation. Due to the association of infertility due to anovulation, the diagnosis is important to establish a multidisciplinary approach to the treatment of these patients.

An androgen profile is performed. A fasting insulin and glucose may also be required. Some PCOS patients may benefit from metformin (Glucophage) therapy.

Post-coital Testing:

This test evaluates the interaction between the sperm and the cervical mucus at mid-cycle and will give information about the ability of the sperm to penetrate the mucus, which depends on adequate estrogen levels.

A speculum is placed in the vagina, as it would be for a pap smear. A syringe without a needle is then used to remove some mucous from the cervical opening. The speculum is then removed and your cervical mucous is examined.

Endoscopy: Diagnostic Laparoscopy and Hysteroscopy

1. Diagnostic and surgical laparoscopy

Laparoscopy has been developed as part of minimally invasive surgery. The reproductive specialist can, through inserting special lenses with fibre optic light sources into the pelvis of the patient, diagnose pelvic pathology under magnification and when necessary , treat these conditions surgically without open surgery (laparotomy). Gynaecological conditions often present in the infertile female is Endometriosis with up to 25 % of infertile women presenting with endometriosis, compared to a background incidence of 8-10% in the general population.

Other common conditions are ovarian cysts, tumours and tubal conditions such as peritubal adhesions, hydrosalpinx (fluid filled obstructed tubes) and previous tubal damage due to sterilization procedures, which can be reversed in some cases.

2. Hysteroscopy

Direct visualization of the inner cervix and the endometrial cavity is possible by inserting a scope into the uterus to diagnose and treat uterine abnormalities such as uterine septums, polyps and fibroids or benign uterine muscle tumours in the wall or cavity. These fibroids or septae may result in either infertility or recurrent pregnancy loss.

Treatment:

Empirical Treatment:

Female patients are treated with periconceptual folic acid (5mg per day) as well as medication where indicated to treat underlying medical conditions i.e. Eltroxin for thyroid abnormalities, Metformin for glucose intolerance and prolactin antagonists for hyperprolactinaemia.

Preconception Counselling:

The risks of genetic abnormalities are discussed for those with a family history or age > 35. Smoking cessation, alcohol restriction, weight loss, marital counselling are recommended as indicated and the unit make use of the services of dedicated Biokineticists, Dietitians and Psychologists with a special interest in Reproductive Health.