Referral to Secondary Care (Ensure results of all investigations are available to secondary care team)

Transcription

1

2 Initial Assessment Give initial advice Give advice on what constitutes infertility Give advice on cumulative probability of pregnancy Advise on frequency of intercourse (every 2-3 days) Lifestyle advice where appropriate: smoking cessation, weight loss if BMI>29, advice on alcohol. Clinically assess the couple Female History: Medical, gynaecological, cervical screening, STIs, occupational history Examination: BMI if >30 offer wt loss/exercise advise Abdomino-pelvic examination Investigations: Rubella status; immunise if susceptible Cervical smear if appropriate Chlamydia trachomatis screening If regular cycles: - Day 21 progesterone or later in long cycle to confirm ovulation; Day 3 (2-4) FSH If irregular FSH, LH, prolactin, oestradiol, testosterone, thyroid function, pelvic ultrasound. Male History: Medical, occupational history, previous urogenital surgery, previous genital pathology, anabolic steroid use Investigations: One semen analysis (WHO methodology) 1 Repeat in 3 months if abnormal If azoospermic, severe oligospermia repeat semen analysis ASAP 1 WHO Guidelines for sperms analyses within 60 minutes of ejaculation: Volume.2ml;PH>=7.2;Concentration.>=20million per ml; Motility: can be as low as 25% if sperm are rapidly motile and good forward progression: Abnormal forms <15%; Antisperm antibodies<50% Discuss with couple and plan future management Advice regular sexual intercourse (2-3 times per week) Give advice as appropriate on smoking, alcohol, drug use and weight Advise folic acid supplementation to the woman 400µg (5mg folic acid if she is epileptic or diabetic and consider referral for pre-conception counselling) Consider early referral to secondary care Woman aged over 35 Amenorrhoea/oligomenorrhoea Previous abdominal/pelvic surgery Previous PID/STI; abnormal pelvic examination If abnormal semen analysis testes Abnormal investigations Defer referral if: Investigations normal in both partners In those with normal investigations if no conception after 18 months of regular unprotected sexual intercourse, refer to secondary care Referral to Secondary Care (Ensure results of all investigations are available to secondary care team)

3 1.1 Appendix 3: Management of Patients in Secondary and Tertiary Care Definition of Infertility Infertility is defined as the inability to conceive despite regular sexual intercourse without using contraception for 2 years The probability of pregnancy Cumulative probability of pregnancy in general population: 84% 1 st year; 92% 2 nd year; 93% 3 rd year Principle of Care for Couples - Couple centred dedicated fertility clinic - Oral and written information - Counselling - Information on self-help groups Initial assessment Duration of infertility coital frequency, contraceptive use, ejaculatory problems Lifestyle issues timing of intercourse, alcohol, smoking, bodyweight, drugs, occupation, stress Medical and sexual history, physical examination Review results of all investigations undertaken in primary care Preconceptional health Folic acid supplementation 400µg (commence on 5mg folic acid if woman epileptic or diabetic and consider referral for preconception counselling) Check rubella status has been performed Check cervical screening Chlamydia trachomatis screening refer couple to GUM if appropriate BMI Dietetic referral if BMI >29

4

5 Investigation And Subsequent Treatment Of Infertility Semen analysis One semen analysis Repeat in 3 months if abnormal WHO methodology 1 Ovulation Check for regular menstruation Serum FSH/LH day 2-4 of cycle Check mid-luteal progesterone (weekly from day 21 for cycles up to 42 days) Endocrine screen if amen/oligomenorhoeic Tubal patency Hysterosalpingogram Laparoscopy and dye if co-morbities Ensure Chlamydia screening prior to procedure (The results of semen analysis and assessment of ovulation must be known before tests for tubal patency are performed) Azoospermia FSH, testosterone, Cystic fibrosis screening, karyotype Obstructive - Surgery and sperm recovery Non-obstructive: - Sperm recovery Testicular failure - Sperm cryopreservation Referral for ICSI (or appropriate assisted conception) Oligozoospermia Unstimulated IUI x 6 cycles (if mild male factor) Ovulatory disorder WHO Grp I (Low FSH & OE) Gonadotrophins (Gn) or pulsatile GnRH WHO Grp II (PCOS) Clomiphene - If not pregnant after 6 ovulatory cycles offer clomiphene assisted IUI for 6 cycles - If not pregnant after the 12 cycles refer for IVF If not ovulating after 6 cycles offer: - Metformin + clomiphene if BMI>25 - Ovarian drilling - Gonadotrophins WHO Grp III (Ovarian failure) Referral for assisted conception Consider donor oocytes or or or Normal Plus normal semen analysis, normal day 3 FSH Unexplained infertility Unstimulated IUI for 6 cycles Failure Tubal occlusion Endometriosis Minimal - Surgical ablation at lap & dye or - Minimal to mildunstimulated IUI x 6 cycles with U/S Mod/Severe: - Surgery or IVF Endometrioma: - Laparoscopic cystectomy Consider tubal surgery if mild tubal disease Consider selective salpingography & tubal cannulation for proximal tubal factor Failure - if hydrosalpinx, consider salpingectomy before IVF Failure Hyperprolactinaemia Investigate: Cannulated prolactin, MRI Consider referral to endocrinologist Referral for IVF

6