Case 4: Primary infertility

 

Case 4: Primary infertility

CASE 4: PRIMARY INFERTILITY

History

A couple attends the gynaecology clinic because of failure to conceive. They stopped

using condoms for contraception 19 months ago. There are no apparent sexual difficulties, and they have been having intercourse two to three times per week. In the last

6 months ovulation has been confirmed by the woman reporting a change in cervical

mucus and a positive home urinary ovulation kit, and they have been having intercourse

around this time.

The woman is 28 years old, with regular 29-day menstrual cycles and no previous gynaecological problems. Both the woman and her partner are generally healthy and have been

together for 7 years. Neither reports any previous sexually transmitted infection.

Examination

The woman’s investigations are normal, with normal gonadotrophins (LH and FSH), and

confirmation of ovulation with a day 21 progesterone test. Chlamydia test is negative and

she is immune to rubella. Hysterosalpingogram confirms patent fallopian tubes and normal

morphology of the endometrial cavity.

INVESTIGATIONS

The semen analysis for her partner is as follows:

Parameter

Normal range (World

Health Organization)

Semen volume 3.2 mL >1.5 mL

Total sperm number 9.6 million 39 million per ejaculate

Sperm concentration 3 million/mL >15 million/mL

Total motility (progressive and non-progressive) 9% >40%

Live spermatozoa 45% >58%

Sperm morphology (normal forms) 3% >4%

Questions

1. What does the semen analysis

show?

2. What further information should

you ascertain from the man?

3. What does the ultrasound show

and what is the significance of this

in this case?

4. What further investigation and

management would you plan for

the management of this couple’s

Figure 4.1 Transvaginal ultrasound infertility?

scan.100 Cases in Obstetrics and Gynaecology

10

ANSWER 4

Semen analysis interpretation

Normal ranges for semen characteristics are published by the World Health Organization

(WHO). The nomenclature applied to abnormal semen quality depends on the degree of

abnormality and the specific type of abnormality. In this case the sample would suggest

oligoasthenoterato-zoospermia (total number and concentration of spermatozoa, and

percentages of both progressively motile and morphologically normal spermatozoa, all below

the lower reference limits).

Further information to be ascertained

The history from the man is insufficient. Further enquiries should include:

• Occupation (infertility has been associated with occupational exposure to chemicals and with scrotal temperature)

• Smoking history

• Alcohol intake

• Previous medical history (cystic fibrosis, mumps or testicular torsion may affect fertility)

• Recent viral illness (may also affect spermatogenesis)

It should be confirmed that the semen sample was provided following the recommended

procedures:

• Collected after at least 48 h but no more than 7 days of sexual abstinence

• Delivered to the laboratory within 1 h of production

• Collected by masturbation and ejaculated into a clean glass or plastic container,

protected from extremes of temperature (below 20°C or above 40°C)

Ultrasound findings

The image shows an ovary which is polycystic in morphology. This is not a relevant factor for

this couple as she has regular periods and the day 21 blood test confirms ovulation.

Further investigation and management

The abnormal sperm quality is the likely cause of infertility, but the semen analysis must

be repeated to confirm that it is not a transient effect, e.g. of a recent viral illness. Causes

of oligospermia may be pretesticular (such as pituitary tumours, smoking or medication),

testicular (such as varicocoele, trauma, mumps or Y chromosome deletions) or posttesticular (such as prostatitis or cystic fibrosis causing vas deferens obstruction). Referral

to an andrologist can be useful in these cases as some causes of oligospermia are amenable

to treatment.

He should also be examined for scrotal size and morphology. Testicular biopsy may be indicated to rule out pathology. Percutaneous sperm aspiration from the testis can be carried out

in a man with complete azoospermia from an obstructive cause (not relevant for this couple

where the man does have some sperm in the seminal fluid).

Assuming the semen quality remains poor on repeat analysis after 3 months, then the couple

will need assisted conception with in vitro fertilization and intracytoplasmic sperm injection

(direct injection of a single sperm into an egg) to achieve a pregnancy.