Infertility management protocol

Infertility is defined as inability of a couple to conceive naturally after one year of regular unprotected sexual intercourse. It is not a major problem in Africa and as a matter of fact, fertility is the problem.

However the problem is creeping into the middle class and it is a major problem that needs attention.

Epidemiology of infertility

For healthy young couples, the probability of getting pregnant are as follows;

  • 20-25%per reproductive cycle,
  • 60% within the first six months
  • 84% within the first one year and
  • 92% within the first two years.

Common causes of infertility

  • Pelvic inflammatory disease and sexually transmitted infection is common in Africa
  • Excess alcohol intake and smoking,
  • Unexplained infertility.

The causes can be divided into male factors like sperm abnormalities and female factors like fallopian tubes dysfunction, and problems with ovulation.

When treating infertility, a good history needs to be taken with both partners involved. This will make unearthing the problem much easier. One partner may be fertile while the other is not or both. In Africa, women used to be thought as the ones who are infertile but at least that notion has changed and men are willing to be tested for fertility and get involved in the whole process.

Clinical examination is done to exclude causes of infertility and at the end of the tests, the medical professional is able to make a provisional which he will work on.

infertility

Investigations

The couple should start investigations 12 months after trying to conceive. If the female partner is more than 35years old, her fertility might be low.

Because there is a correlation between hormone levels and fertility, hormone levels should be investigated.

Sperm health should be investigated as it is also a major cause of infertility. Female factors like patency of the fallopian tubes, and ovarian hormone levels. Levels of follicle stimulating hormone, lutenizing hormone and progesterone should be tested. These hormones levels should checked whether they vary from the expected levels in the menstrual cycle. If the couple had done some previous test, have a look at the tests.

For a woman with chronic anovulation, presenting with hirsutism (male pattern hair) test for serum levels of androgens and find the source of excess androgens. Test serum levels for sex hormone binding globulin dihydroepiandrostenedione (DHEA), dihydroepiandrostenedione-sulfate (DHEAS) and prolactin.

To increase chances of pregnancy, we recommend referring patients to specialized fertility clinics.

 In some cases, the cause of infertility or subfertility could not be suspected from the history taking and clinical examination. In such circumstances, it is recommended not to prescribe any medication until all basic investigations are done and its results received.

Treatment

Treatment depends on the cause of the infertility. Ovulation inducing medications like clomiphene, letrozole may be given if it’s the female partner who has a problem. If the tubes are not patent, surgical treatment (such as laparoscopy and hysteroscopy) may be required.  Different assisted reproduction techniques like invitro fertilization may be required.

Male partners maybe treated with testosterone drugs. This maybe in form of injection (testosterone) or oral testosterone analogues like mesterelone.

Cystic ovarian syndrome may be managed with metformin together with other medications. Other medications that improve fertility are ovacare (for women) and oligocare (for men). The effectiveness of Hyponidd in treatment of infertility in women has not been tested but most gynecologists prescribe it.

Counseling

The clinician should also focus on emotional needs of the patients and give them the full information on what is going on.  Let the patient know that the chances of live birth with assisted reproduction techniques (ART) is 50%. This depend again on age with best outcomes in the age of23-39 in females.

Advice the patients on healthy lifestyle which includes weight reduction and avoiding fast foods.

Make the patients know that treatment of infertility is a long process and requires patience. Sometimes the doctor may feel inadequate but this is a complex problem. Let the patients know that the chances of malformations in invitro fertilization is about 2-%.

Lastly, infertility is not a life threatening condition. Management of infertility is difficult and patients should be informed so as to have realistic expectations

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Dr Mathu

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