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.
• Pregnancy History: History of previous pregnancies, even unsuccessful ones, may provide insight into fertility potential.
• Medical History: Assess for conditions like thyroid disorders, diabetes, and mumps or undescended testes in men.
• Family History: Look for genetic conditions.
• Lifestyle Factors: Smoking, alcohol use, drug use, obesity, and stress may impact fertility.

Physical Examination

• General exam: Signs of hypogonadism (e.g., gynecomastia, small testes).
• Genital exam: Testicular size, presence of varicocele, absence of vas deferens.
• Signs of androgen deficiency: Body hair, fat distribution, muscle mass.

Basic Investigations

• Thyroid Function Tests: To rule out hypothyroidism or hyperthyroidism.
• Semen Analysis: The primary test to assess sperm count, motility, and morphology.
• Hormonal Assays: FSH, LH, testosterone, and prolactin levels to assess for hypogonadism or other hormonal imbalances.
• Scrotal Ultrasound: To check for structural abnormalities like varicocele or absence of vas deferens.

Further Investigations

• Genetic Testing: Karyotyping or Y-chromosome microdeletion testing in cases of azoospermia or severe oligospermia.
• Testicular Biopsy: To differentiate between obstructive and non-obstructive azoospermia.

Treatment Approaches: Lifestyle Changes

• Maintain a healthy weight, avoid smoking, alcohol, and drugs.
• Timed intercourse during ovulation to maximize chances of conception.
• Medications: Sperm Stimulation (for Men): Hormonal therapy (e.g., hCG, GnRH) to stimulate spermatogenesis.
• Surgical Interventions: For Men: Varicocelectomy or vasovasostomy for obstructive azoospermia.
• 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.

Subfertility in Men

Cause	Diagnosis	Management
Semen Abnormalities (Low sperm count, poor motility)	Semen Analysis: Evaluates sperm count, motility, and morphology. Hormonal Assays: LH, FSH, testosterone levels. Scrotal Ultrasound: To assess structural abnormalities like varicocele.	Lifestyle Changes: Smoking cessation, alcohol reduction, weight management. Medications: Hormonal treatments if hypogonadism is diagnosed (e.g., clomiphene, hCG). Assisted Reproductive Techniques (ART): Intrauterine insemination (IUI) or in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) if sperm abnormalities persist.
Obstructive Azoospermia (Blocked vas deferens or epididymis)	Physical Examination: Absence of vas deferens (in cases of cystic fibrosis or congenital absence). Scrotal Ultrasound: To detect ductal obstruction. Testicular Biopsy: To confirm sperm production in the testes.	Surgical Correction: Vasovasostomy or epididymovasostomy if obstruction is treatable. Sperm Retrieval: Testicular sperm extraction (TESE) followed by IVF/ICSI if surgical correction is not feasible.
Varicocele (Dilated veins in the scrotum)	Physical Examination: "Bag of worms" sensation on palpation. Scrotal Ultrasound with Doppler: To confirm venous dilation.	Surgical Repair (Varicocelectomy): Indicated for symptomatic cases or in men with subfertility. Assisted Reproduction: IUI or IVF in severe cases where surgery is not sufficient.
Hormonal Imbalance (Hypogonadotropic hypogonadism)	Hormonal Assays: FSH, LH, testosterone, and prolactin levels to detect hormonal abnormalities. Imaging: MRI of the pituitary gland to rule out pituitary tumours if indicated.	Hormonal Therapy: hCG or GnRH therapy to stimulate sperm production. Lifestyle Management: Address stress, nutrition, and obesity, which may contribute to hormonal imbalances.
Genetic Factors (Klinefelter syndrome, Y-chromosome microdeletion)	Karyotyping and Genetic Testing: To detect chromosomal abnormalities or Y-chromosome microdeletions.	Genetic Counseling: Provide guidance on reproductive options, including IVF with donor sperm if necessary. ART: In cases of mild genetic defects, TESE with ICSI may be an option.