For Doctors

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

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