for-doctors-1

Fertility checklist

When a patient seeks advice for fertility problems, it is important to conduct good history-taking to rule out possible causes.

This includes:

  • Current menstrual history to determine the likelihood of ovulation
  • Medical disorders that affect fertility such as hyper/hypothyroidism, prolactinoma, PCOS, hypothalamic pituitary disease, anorexia, weight loss, Cushing or premature ovarian failure
  • Factors associated with tubal blockage such as previous history of abdominal operation, PID, STD, endometriosis, adhesions
  • Social history such as smoking, alcohol, drugs
  • Factors that may affect male fertility such as testicular hyperthermia; concurrent illnesses or use of recreational drugs (sulphasalazine, nitrofurantoin, tetracyclins, Cimetidine, ketoconazole, colchicine, allopurino, Alpha-blocker, propanolol, ankylating agent, Cannabis, cocaine, anabolic)
  • Coital history such as frequency of unprotected intercourse

Investigations

Female

  • FSH, LH, E2
    (measured on D2-D6)
  • Progesterone test (D21)
  • TSH, prolactin, testosterone
    (measured if period shortened, prolonged, irregular)
  • Rubella, Hep B, HIV, VDRL
  • Pap Smear
  • Ultrasound (PCOS, fibroid)
  • Tubal patency test

Male

  • Rubella, Hep B, HIV, VDRL
  • Semen analysis
    (taken after 2-3 days abstinence,
    repeat after 6 weeks if results
    are abnormal)

First line of treatment

  • Pre-existing medical problem

    • - Stabilize medical condition
      – Optimize drug usage
      – Refer to Obstetricians

  • Weight

    • - Check BMI
      – Advice weight gain or loss if BMI 30

  • Smoking

    • - Advise both partner to stop smoking

  • Folic acid

    • - Should take 0.4mg daily
      – Advice 5mg daily if history of NTD or epilepsy

  • Virology

    • - Screen for Rubella immunity
      – Screen for HIV, Hep B, Hep C in high risk group

  • Timing of intercourse

    • - Check couple’s understanding of ovulatory cycle and fertile date
      – Advise on regular intercourse (2-3 times a week)

  • Factors affecting fertility

    • - Discuss any factors that warrant early referral

Factors that warrant referral

Female

  • Age >35
  • Previous ectopic pregnancy
  • Known tubal disease/PID/STD
  • Previous tubal/pelvic surgery
  • Amenorrhea/Oligomenorrhea
  • Presence of big fibroid

Male

  • Testicular maldescent/ orchidopexy
  • Chemo/radiotherapy
  • Previous urogenital surgery
  • History of STD
  • Varicosele