CLINICAL CASE

DISCUSSION

Mohd Hanif Gandoh

131303241
• A 29 year old woman and her partner are seen in the
gynaecology outpatient clinic with inability to conceive.
They stopped using condoms 2 years ago and have had
regular intercourse since then. There is no difficulties
during coitus such as dyspareunia, erectile dysfunction
or premature ejaculation.
• The woman also has no specific previous medical history
except for an appendectomy at age 12 year old. Her
periods occur every 30-35 days and can be heavy at
times but not painful. There is no intermenstrual or
postcoital bleeding. She has always had normal smears
and has never had any sexually transmitted infections.
She takes no medications, drinks approximately 6 units
of alcohol per week and does not smoke. She works as
a clerk and is not on constant stress.
• The partner has no previous medical or surgical history.
He is not on any medications or abuse of anabolic
Physical examination

• On examination, her BMI is 29kg/m2

• She has slight acne on her face and her
chest
• There are no abdominal scars and the
abdomen is non-tender with no masses
palpable
• Speculum and bimanual examination are
normal
Investigations

• Semen analysis showed sperm count 30

million/ml, 60% progressively motile in the
1st hour and 55% were normal sperms
Blood investigations taken on 3rd day of menstrual cycle

HORMONES VALUES NORMAL

VALUES
LH level 6.2 IU/L Day 2-5
0.5-14.5 IU/L
FSH level 3.1 IU/L Day 2-5
1-11 IU/L
Free T4 1.5 mIU/ml 0.7-2.0 mIU/ml

TSH 3.4 mIU/ml 0.4-4.0 mIU/ml

Prolactin 19 ng/ml 3-29 ng/ml

Testosterone 4.1 nmol/L 0.8-3.1 nmol/L

Mid luteal phase 15 nmol/L
progesterone
Transvaginal ultrasound scan

Both ovaries show peripherally placed 12 follicles ranging from

7-9mm in size. The ovarian volume is 12 ml
Primary and Secondary
Infertility
Infertility
• Inability to conceive following one year of
regular unprotected coitus
• In Malaysia, 1 out of 7 is affected
• Primary: no previous pregnancies
Secondary: at least one prev pregnancy
• Male: 25%
Female: 35%
Combined: 30%
Unexplained: 10%
Aetiology
MALE
Impaired sperm production
- Hypothalamic-pituitary (Kallman’s,
craniopharyngioma)
- Chromosomal, cryptochordism
- Faulty descent of testes
- TB, DM
- Infection (mumps orchitis)
- Smoking, alcohol,drugs
Obstruction of sperm transport
- Trauma
- Congenital obst. of epididymis
- Infection (obstruction of the vas)
Ejaculatory problems
- Erectile dysfunction
- Retrograde ejaculation
- Premature ejaculation
FEMALE
Anovulation/oligoovulation
- PCOS
- Hyperprolactinemia
- Hypothyroidism
- Premature ovarian failure
Anatomical & tuboperitoneal
dysfuntion
- Uterine (fibroids)
- Cervical (antisperm Ab, stenosis)
- Vaginal (infection)
- Endometriosis
- Salpingitis (PID)
History
MALE FEMALE
- Infertility (duration, prior hx of fertility)
- Coitus (freq, timing, difficulties eg; dyspareunia,premature ejac,
erectile
dysfx)
- Hx of undescended testes, - Age
ambigous - Diet, stress
genitalia, trauma, genital surgery - Menstrual hx (irregular menses,
(orchidoplexy, testicular torsion) dysmenorrhea, dyspareunia)
- Sexually transmitted infections - Prev pregnancies, outcome and
- Systemic dx (DM, HT) complications
- Medications (Bblockers, chemo, - Prev pelvic/ abd infection (PID,
anabolic steroids) ruptured appendix, Chlamydia,
- Lifestyle (Smoking, drugs, Gonnorhea)
alcohol) - Prev abdomino-pelvic surgery
- Environmental (temperature, (adhesion and tubal impairment)
radiation exposure) - Lifestyle (smoking, alcohol,
drugs)
Physical Examination
MALE
Done after semen analysis
- General appearance (2⁰ sexual
characteristics)
- Abdomen (surgical scars -
undescended testes)
- Location of urethral meatus
(hypospadias)
- Scrotum (surgical scars)
- Testis (size, consistency)
- Epididymis (fullness, tenderness)
- Vas deferens (palpable along
course)
- Varicocelle (bag of worms)
FEMALE
- BMI (obese or low)
- Hirsuitism (PCOS)
- Thyroid enlargement (Thyroid
dysfx)
- Breasts (galactorrhea)
- Abdomen (mass)
- Pelvic examination (enlarged
uterus,
retroverted uterus, adnexal
masses)
Investigations

MALE FEMALE
- Semen analysis - Mid luteal serum
- Hormone testing progesterone
- Genetic tests - Prolactin
- testicular biopsy - TFT
- FSH,LH
- Androgens
- Ultrasound
- Tubal Patency Tests
- Rubella and Chlamydia
screening
- Hysteroscopy
Investigations (FEMALE)
Mid-luteal progesterone level
• To confirm ovulation (>30nmol/L)
• Regular 28 days cycle  day 21
• Irregular cycle  1 week prior to
menstruation

Serum Prolactin
• If amenorrhea, oligomenorrhea, galactorrhea
• Repeat if higher than normal
• If significantly higher, consider pituitary fossa
MRI
Thyroid function test
• If irregular menses or hyperprolactinemia
Serum FSH and LH
• If amenorrhea
• High FSH, consider karyotyping to rule out
chromosomal abnormalities
• < 40 years old with 2⁰ amenorrhea and high
FSH, consider Premature ovarian Failure
• Low FSH and LH, consider
hypogonadotrophic hypogonadism
Androgens (DHEAS,Testosterone)
• If PCOS is suspected
Ultrasound
• May reveal underlying pathology (ovarian
cysts, hydrosalpinx, fibroids, adenomyosis)
Tubal Patency Tests
• Hysterosalpingography (HSG) – Non invasive.
Contrast medium is injected and visualized with U/S
• Laparoscopy – invasive, directly visualized via
telescope inserted thru umbilicus
• Hysterosalpingo-contrast-sonography
(HyCoSy)
Hysteroscopy
• Direct visualization using hysteroscope under
anaesthesia
Investigations (MALE)
Semen Analysis (WHO 2009)
Parameter Lower reference limit
Semen volume 1.5 ml
pH 7.2
Sperm concentration 15 mil spermatozoa per ml
Total motility 40%
Progressive motility 32%
Sperm morphology 30-40% normal forms

• If the values fall below reference limit it does not

necessarily means infertility
• If below reference limits  repeat after 3 months
 Abnormalities
Aspermia: absence of semen
Azoospermia: absence of sperm
Hypospermia: low sperm volume
Oligozoospermia: low sperm count
Asthenozoospermia: poor sperm motility
Teratozoospermia: sperm carry more morphological defects than
usual

• Low volume may suggest incomplete collection, short

abstinence interval, ejaculatory dysfunction, or
obstructive pathologies
• Azoospermia may be due to obstructive/non obstructive
• Asthenozoospermia may be due to antisperm Ab,
infection, varicocele
Serum FSH,LH and Testosterone levels
• If abnormal semen analysis
• High FSH  Testicular problem
Low FSH  Hypothalamic/pituitary
problem
• low testosterone  hypothalamic pituitary
failure

Genetic testing
• If severe oligozoospermia/azoospermia
Imaging
• Indicated when physical examination
identifies lump/mass
• Scrotal U/S  testicular volume and
morphology

Testicular biopsy
• azoospermia - able to differentiate
between obstructive and testicular
pathology.
Treatment (MALE)

Lifestyle modification
• Quit smoking and alcohol
• Avoid wearing tight undergarments

MEDICAL
• Abnormal semen analysis  low dose
clomiphene citrate (3 months)
• If only asthenospermia  antioxidant
coenzyme Q10
• Erectile dysfunction  sildenafil citrate
SURGERY
• Focused on correcting the blockage as to
facilitate the ejaculation of sperms and
improve fertility
• varicocele -varicocelectomy
Treatment (FEMALE)

Lifestyle modification
• Quit smoking and alcohol. Reduce/gain
weight and avoid stress

MEDICAL
Clomiphene citrate
• 50mg from D2 of the cycle for 5 days
• Should not exceed 150mg  OHSS
• Not advisable to use > 6 cycles  high risk
for ovarian Ca
Gonadotrophin
• hMG and recombinant FSH in combination
with clomiphene

Metformin
• Insulin sensitizers
• Facilitates ovulation induction in obese PCOS
• Prevents miscariages in PCOS women
• 500mg OD / 850mg BD

Dopamine antagonist
• Hyperprolactinemia
• Bromocriptine 2.5-20mg in divided doses BD
SURGERY
• Laparoscopic cauterization of
endometriotic deposits
• Adhesiolysis (PID, endometriosis)
• Myomectomy  fibroids
• Ovarian drilling  if PCOS resistant to
clomiphene
Management Plan

• Counselling regarding infertility

• Advice lifestyle modification (control diet,
reduce weight, exercise regularly)
• Start Tab. Metformin 500mg OD
• Start Tab. Clomiphene citrate 50mg for 5
days from D2-D6
REFERENCES
• National Institute of Health and Care Excellence.
Fertility: Assessment and treatment for people with
fertility problems. NICE clinical guideline 156. NICE
UK 2013
• Clinical Protocols in Obstetrics and Gynaecology in
Malaysian Hospital, First Edition, 2015
• Gynaecology Today, Revised Edition, 2012
• Hacker and Moore’s Essentials of Obstetrics and
Gynaecology, Fifth Edition, 2010
• Balan A. The Polycystic Ovary Syndrome: guidance
for diagnosis and management. Polycystic Ovary
Syndrome UK
• Jungwirth et al. Guidelines on Mle Infertility. European
Association of Urology 2012