Infertility

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Chapter 32 Infertility

A couple who have had regular unprotected intercourse for a period of 12 months without a pregnancy occurring is considered to be infertile and may seek help from a medical practitioner. Infertility affects 10–15% of couples. It is important to understand that humans like other primates are relatively subfertile.

During the first cycle 30% of couples will achieve pregnancy. During the second cycle a further 30% of couples will be successful and 80% will conceive in the first year. In the first three cycles, 30% of the conceptions will end in miscarriage, and almost half these miscarriages occur so early they are undetected except by a positive β-hCG pregnancy test

FACTORS IN INFERTILITY

The factors that may be involved in the couple’s infertility vary depending on local conditions, the population investigated and the referral procedures. Analyses reported by several clinics of large numbers of patients in the past two decades are given in Table 32.1. In a quarter of cases, more than one of the factors is believed to be involved.

Table 32.1 Factors in infertility

Factor	Percentage of Cases
Male
Defective sperm production, insemination difficulties	30–40
Female
Ovulation factors	5–25
Tubal or uterine factors	15–25
Cervical/immunological factors	5–10
Unexplained after investigations	10–25

INVESTIGATION OF INFERTILITY

Of the many investigations suggested over the years, most have been found to be of little value, and today there is relative agreement about what tests should be made to reach a diagnosis.

In most cases the woman makes the first contact with a health professional. During this visit, the doctor should obtain information about the history of past illnesses and operations; the woman’s menstrual history; and the couple’s sexual behaviour, including frequency of sexual intercourse. Some women are concerned that they do not have an orgasm and that semen runs out of the vagina. The doctor should reassure the woman that neither of these affects her fertility.

A general physical examination, including a pelvic examination, is made to exclude any current disease. The pelvic examination is performed to detect any gross abnormalities of the genital tract, such as uterine myomata, ovarian tumours and endometriosis (see later). If a cervical smear (Pap smear) has not been taken in the previous year this should be done. Also, laboratory tests should be ordered and should include a full blood examination, including tests for syphilis, rubella and HIV infection, and a urine analysis. If the woman has attended during the luteal phase of her menstrual cycle, blood may be taken to measure the progesterone level to establish whether she is ovulating.

Having completed these initial investigations the medical practitioner should outline the investigations that will be carried out, and their sequence. It is customary to start with a seminal analysis, as the man may have azoospermia or severe oligospermia. This finding would make further examinations of the woman unjustified initially.

Seminal analysis

Ideally, a man should accompany his partner at the first visit so that the investigation plan can be discussed with them both, a history can be obtained from the man, and the man can also be examined. However, it is unusual for a man to attend with his partner. Because of this, and intercourse, the first step is to arrange for a semen analysis, and only if this is abnormal need the man be seen.

The seminal specimen can be obtained in two ways. The man can either attend the laboratory and masturbate there and so provide a fresh seminal specimen, or he can masturbate at home (or have his partner masturbate him) and ejaculate into a clean, dry glass container. This is then taken to the laboratory within 1 hour, and the analysis made.

Standards for a normal seminal specimen have been developed by the World Health Organization (WHO) and are shown in Box 32.1. If the first seminal appraisal is abnormal, two further specimens should be evaluated before a prognosis is made. The most important predictors of male fertility are the percentage of motile sperm, the quality of the motility of the sperm, the motile sperm concentration, the total motile count and the sperm morphology. The absolute count is not a good predictor.

Box 32.1 Normal seminal analysis

Volume	>2 mL
Sperm concentration	>20 million per mL
Total sperm count	40 million
Motility 60 min after ejaculation	>50% with normal progression
Morphology	>30% with normal morphology

When the sperm count is less than 20 million per mL, abnormal morphology and motility is often found

The semen analysis is traditionally graded as:

• Oligospermia (a count of less than 20 million sperm per mL)

• with normally motile sperm

• with asthenospermia

• Severe oligospermia (less than 5 million sperm in total specimen)

• Azoospermia

• Asthenospermia with normal sperm count.

Abnormal results indicate that the man should be examined and a history taken. The history may show that he is exposed to high heat, certain chemicals, or is taking anticancer drugs. The examination of the man’s genitals is important. The size of his testicles is evaluated and his scrotum is palpated, with the man standing, to detect if he has a varicocele. Treatment of the varicocele has been shown to be beneficial only if the man is oligospermic, as this will double the chance of pregnancy. If azoospermia or severe oligospermia is diagnosed, blood is drawn to measure the level of follicle-stimulating hormone (FSH). A raised level (three times the normal upper limit) indicates testicular failure. If severe oligospermia is diagnosed and the testicular volume and FSH levels are normal, a testicular biopsy is sometimes taken.

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