Makindo Medical Notes

Initial Assessment

• Duration of Infertility: Subfertility is defined as failure to conceive after 12 months of regular, unprotected intercourse.
• Sexual History: Frequency and timing of intercourse, sexual dysfunction, issues with ejaculation or erection in men.
• Contraception History: Previous contraceptive use and timing of discontinuation.
• Pregnancy History: History of previous pregnancies, even unsuccessful ones, may provide insight into fertility potential.
• Menstrual History (for women): Regularity, cycle length, signs of ovulation, and dysmenorrhea.
• Medical History: Assess for conditions like PCOS, thyroid disorders, diabetes, endometriosis, or pelvic inflammatory disease in women.
• Family History: Look for genetic conditions, premature ovarian insufficiency, or recurrent miscarriages.
• Lifestyle Factors: Smoking, alcohol use, drug use, obesity, and stress may impact fertility.

Physical Examination

• General exam: BMI, hirsutism, acne, signs of androgen excess (PCOS).
• Pelvic exam: Check for infections, fibroids, adnexal tenderness, or pelvic masses.
• Thyroid exam: Evaluate for thyroid enlargement or nodules.

Basic Investigations

• Ovulation Testing: Basal body temperature (BBT), serum progesterone on day 21 to confirm ovulation.
• Thyroid Function Tests: To rule out hypothyroidism or hyperthyroidism.
• Prolactin Levels: Elevated prolactin may inhibit ovulation.
• Ovarian Reserve Testing:
  • Day 3 FSH and estradiol levels to assess ovarian reserve.
  • Anti-Mullerian Hormone (AMH) to estimate ovarian reserve.
• Pelvic Ultrasound: Assess antral follicle count (AFC) and detect anatomical issues like polycystic ovaries, fibroids, or endometriomas.
• Hysterosalpingography (HSG): Evaluate fallopian tube patency and uterine cavity for structural abnormalities.

Further Investigations

• Laparoscopy: To diagnose endometriosis or pelvic adhesions, especially in cases of unexplained subfertility or pelvic pain.
• Hysteroscopy: To evaluate and treat uterine abnormalities (e.g., polyps, fibroids, septa).

Treatment Approaches

• Maintain a healthy weight, avoid smoking, alcohol, and drugs.
• Timed intercourse during ovulation to maximize chances of conception.
• Medications: Ovulation Induction (for Women): Clomiphene citrate, letrozole, or gonadotropins.
• Surgical Interventions

  For Women: Surgical repair of uterine or tubal abnormalities (e.g., myomectomy, tubal microsurgery).

• Assisted Reproductive Technologies (ART)
  • Intrauterine Insemination (IUI): Sperm is placed directly into the uterus.
  • In Vitro Fertilization (IVF): Fertilization occurs outside the body, and the embryo is implanted in the uterus.
  • Intracytoplasmic Sperm Injection (ICSI): A single sperm is injected into the egg, useful for male subfertility.

Psychological and Emotional Support

• Counseling: Offer psychological support or therapy to address the emotional impact of subfertility.
• Support Groups: Connect patients with support groups to share experiences and gain emotional support.

Referral to Specialist

• Referral to Fertility Specialist: For couples who do not conceive after basic treatments or those with complex fertility issues, early referral is recommended.
• Refer women over 35 years of age or with known fertility issues for specialized care sooner.

Causes of Subfertility in Women

Cause	Diagnosis	Management
Ovulatory Disorders (Anovulation, Polycystic Ovary Syndrome - PCOS)	Menstrual History: Irregular or absent menstrual cycles. Hormonal Assays: FSH, LH, estradiol, testosterone, prolactin levels. Pelvic Ultrasound: To assess for polycystic ovaries (in PCOS) or other ovarian pathology.	Ovulation Induction: Clomiphene citrate or letrozole to stimulate ovulation. Weight Loss: For women with PCOS, weight loss can restore ovulation. ART: IVF if ovulation induction fails.
Endometriosis	Pelvic Pain: Dysmenorrhea, dyspareunia, or chronic pelvic pain. Pelvic Ultrasound: To assess for endometriomas. Laparoscopy: Gold standard for diagnosis and staging.	Laparoscopic Surgery: Removal of endometriotic lesions. Hormonal Therapy: GnRH agonists or oral contraceptives to suppress endometriosis progression. ART: IVF for severe cases where surgical treatment is insufficient.
Tubal Factor (Blocked fallopian tubes)	Hysterosalpingography (HSG): X-ray to assess for tubal patency. Laparoscopy: For direct visualization of tubal anatomy.	Surgical Repair: Tubal microsurgery in selected cases. ART: IVF is often the best option for women with tubal damage.
Uterine Factors (Fibroids, congenital anomalies)	Pelvic Ultrasound: To assess for uterine fibroids or structural anomalies. Hysteroscopy: To evaluate and treat intrauterine pathology.	Surgical Removal: Myomectomy for fibroids or repair of uterine anomalies. ART: IVF may be required if surgical correction is not possible or fails.
Premature Ovarian Insufficiency (Early menopause)	Hormonal Assays: FSH, LH, estradiol levels to confirm ovarian insufficiency. Karyotype Testing: To rule out genetic causes like Turner syndrome.	Hormonal Replacement Therapy (HRT): For symptom management and long-term health. ART: IVF with donor eggs is often the only option for achieving pregnancy.