Case 16: Infertility

 

Case 16: Infertility

CASE 16: INFERTILITY

History

A 31-year-old woman and her 34-year-old partner are referred by the general practitioner because of primary infertility. They have been trying to conceive for over 2 years. The

woman has regular menstrual periods, bleeding for 4 days every 28–30 days. Her periods

are not heavy and have never been painful. There is no intermenstrual bleeding or discharge and no postcoital bleeding. She has never been diagnosed with any sexually transmitted infections.

The last smear was normal 1 year ago. She is a non-smoker and drinks alcohol very occasionally.

The partner’s only previous medical history was an appendectomy and a course of antiHelicobacter therapy after he developed epigastric pain and was diagnosed with the infection.

He previously smoked 20 cigarettes per day and drank up to 28 units of alcohol per week but

has now stopped smoking and significantly reduced his alcohol intake. He works as buyer for

a retail company.

The couple has intercourse 1–4 times per week and there is no reported sexual dysfunction or

pain on intercourse. They both deny recreational drug use.

Examination

On examination the woman has a body mass index of 23 kg/m2. There is no hirsutism or acne.

There are no signs of thyroid disease. The abdomen is soft and non-tender. Speculum and

bimanual palpation are unremarkable. Genital examination of the partner is also normal.

INVESTIGATIONS

Normal range

Follicle-stimulating hormone (day 3) 4.2 IU/L Day 2–5

1–11 IU/L

Luteinizing hormone (day 3) 2.7 IU/L Day 2–5

0.5–14.5 IU/L

Day 21 progesterone 45 nmol/L

Prolactin 374 mu/L 90–520 mu/L

Testosterone 2.0 nmol/L 0.8–3.1 nmol/L

Semen analysis

Volume 4 mL 2–5 mL

Count 63 million/mL >20 million/mL

Normal forms 22 per cent >15 per cent normal shape

Motility 53 per cent >50 per cent progressively

progressively mobile mobile

Rubella antibody: immune

Chlamydia: negative

A hysterosalpingogram is shown in Fig. 16.1.100 Cases in Obstetrics and Gynaecology

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Questions

• How do you interpret the investigation results?

• Are any further investigations necessary?

• How would you manage this couple?

Figure 16.1 Hysterosalpingogram.Case 16: Infertility

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ANSWER 16

Day 21 progesterone above 30 nmol/L confirms ovulation, and this is supported by normal

follicle-stimulating hormone (FSH), luteinizing hormone (LH) and prolactin. Normal testosterone suggests that polycystic ovaries is an unlikely diagnosis.

The semen analysis is normal, and therefore any male factor aetiology is unlikely. Rubella

immunity should always be confirmed.

The hysterosalpingogram shows fill of contrast medium into both uterine tubes but no spill,

suggesting tubal obstruction as the cause of the fertility problem.

Further investigation

Tubal blockage on hysterosalpingogram can sometimes be due to tubal spasm, and therefore

a laparoscopy and dye is needed to confirm the pathology and also to determine a cause such

as adhesions from previous infection or possibly endometriosis (although the history does

not support this diagnosis).

Management

If the tubes are found at dye test to be patent, then this would suggest that it is feasible to

attempt pregnancy with in utero insemination. However if blocked tubes are confirmed

then in vitro fertilization (IVF) is indicated. Abnormal tubes are usually removed prior

to IVF, as success rates for pregnancy are better and ectopic pregnancy rate reduced after

bilateral salpingectomy.

General advice should be given to take folic acid 400 mg daily to reduce the risk of neural

tube defects, and to the partner to minimize his alcohol intake.

In this case the laparoscopy showed bilateral hydrosalpinges and adhesions as well as perihepatic ‘violin-string’ adhesions. These findings are consistent with previous infection with

chlamydia (or more rarely gonorrhoea). It is not unusual to find such severe pelvic adhesions even when there has never been a clear clinical history of pelvic infection or sexually

transmitted infection. Although the infection may be long ago, it is sensible to treat both the

woman and her partner with a course of antibiotics for pelvic inflammatory disease.

KEY POINTS

• Infertility may be due to anovulation, tubal or endometrial/uterine pathology as

well as male factors.

• Up to 30 per cent of infertile couples have more than one factor causing infertility.

• Tubal obstruction on hysterosalpingogram is not always confirmed at laparoscopy.