New aid to identify rectal bleeding risks
In this series GPs put their burning questions on clinical management to an expert. This week Dr Scott Wilkes answers questions from Dr Linden Ruckert
1. Can couples do anything to help improve their fertility?
Yes. Women with a BMI >29kg/m2 should be encouraged to lose weight as this is likely to increase their chance of conception. Men should avoid testicular hyperthermia and intercourse should take place every two to three days to allow adequate spermatogenesis. Couples should be advised to stop smoking, limit the use of alcohol and avoid the use of recreational drugs.
2. What should we tell women about their likely time of ovulation?
The normal menstrual cycle is 26 to 35 days. Ovulation occurs 14 days before the onset of menstruation. For example, a woman with a 28-day cycle will ovulate on day 14 and a woman with a 35-day cycle will ovulate on day 21. The predicted day of ovulation can only be estimated in retrospect following the onset of menstruation.
Mid-luteal progesterone estimation in a woman with a 28-day cycle should occur on day 21 and for a 35-day cycle will be on day 28. Temperature charting and urine ovulation prediction kits should be avoided as they merely serve to create anxiety.
3. What tests should GPs do and when?
People who have not conceived after one year of regular unprotected intercourse should be offered further clinical investigation. If there is a history of predisposing factors for infertility (such as pelvic inflammatory disease, oligomenorrhoea, amenorr- hoea, undescended testes) investigation should begin immediately.
The initial investigations include FSH/LH, midluteal progesterone and semen analysis. Some GPs may have direct access to tubal assessment such as hysterosalpingography. Women with cycles <26 days="" or="">35 days should also have their prolactin, testosterone, oestradiol and thyroid function estimated. NICE guidelines recommend the initial assessment include:
·semen analysis on behalf of all couples; if first is abnormal repeat three months later
·taking of menstrual history to assess ovulation; if regular, advise woman they are ovulating and confirm with mid-luteal progesterone
·temperature chart use is not recommended
·measuring FSH and LH in women with irregular cycles
·checking thyroid function in women who have thyroid disease symptoms
·women who have galactorrhoea should have their serum prolactin measured
·before undergoing uterine instrumentation, women should be offered Chlamydia trachomatis screening.
4. How do we interpret a low sperm count?
Semen analysis is the most important initial investigation. Referral should not be delayed for couples who have an abnormal semen analysis, as they often require specialist help with assisted reproduction, in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). The World Health Organisation reference values for semen analysis are as follows:
·volume: 2.0ml or more
·sperm concentration: 20 million per ml
·total sperm count: 40 million per ml
·motility: 50 per cent or more progressive (25 per cent or more rapidly progressive )
·morphology: 30 per cent or more (15 per cent or more based on strict morphological criteria)
·white blood cells: less than a million per ml
The sample should be produced by masturbation into a clean sterile container following three days' abstinence from intercourse and delivered to the laboratory within one hour of production to avoid a falsely abnormal result.
5. Is it possible to accurately predict ovarian reserve?
No. Tests of ovarian reserve, including Inhibin B, have poor sensitivity and specificity and are not recommended. Women who have high levels of FSH and LH should be informed that they have reduced fertility.
6. What advice can I give a woman with polycystic ovarian syndrome (PCOS)?
The most common cause of ovulatory dysfunction is PCOS, which is associated with obesity, hirsutism and oligomenorrhoea. These patients usually have elevated LH and testosterone and normal FSH and oestradiol. Weight loss is an important treatment for this group of patients. Clomifene citrate is likely to induce ovulation in these patients.
Ovulation induction with gonadotro-phins is also recommended in this group of patients, however ovarian drilling is equally effective and is not associated with the risks of ovulation induction.
7. What are the indications and success rates for assisted reproduction?
The three main types of assisted reproduction are intrauterine insemination (IUI), IVF and ICSI.
·IUI, where treated sperm from the partner (or donor) is injected into the uterine cavity with or without ovulation induction, is indicated for endometriosis, unexplained infertility or oligospermia. The success rate of assisted reproduction is reported as live births per treatment cycle, also known as the 'take-home baby rate'. The success rate for IUI is of the order of 15 per cent per cycle.
· IVF is where eggs produced with or without ovulation induction are retrieved and mixed with sperm in vitro to produce an embryo, which is transferred to the uterus two to three days later. The indications for IVF are a woman aged 23 to 39, an established cause of infertility such as azoospermia or bilateral tubal occlusion, or unexplained infertility of three years' duration. The success rate for IVF is approximately 15-20 per cent. · ICSI is where one sperm is injected into an unfertilised egg obtained from ovarian stimulation. The indications for ICSI are severe deficits in semen quality, obstructive or non-obstructive azoospermia. The success rate for ICSI is 20-30 per cent. In general the success rates decline with age, falling markedly beyond the age of 40 for women.
8. What are the risks with ovarian stimulation?
The main risks are ovarian hyper-stimulation syndrome, multiple pregnancies and ovarian cancer. Ovulation induction with clomifene, an anti-oestrogen, can be carried out in general practice with appropriate mid-luteal progesterone monitoring. This view, however, is contested. The Committee on Safety of Medicines recommends women not to take clomifene for longer than six months following an increased risk of ovarian cancer with more than 12 months' use. Ovulation induction with gonadotrophins carries a higher risk of side-effects and should only be used by fertility specialists.
9. Where can I find IVF league tables and what do they mean?
A guide to treatments and service provision throughout the UK can be found on the Human Fertilisation and Embryology Authority (HFEA) website www.hfea.gov.uk and its publication HFEA Directory of Clinics. Information can also be found on the Infertility Network UK website. Success rates of the clinics for the various treatments are also available on the website.
Scott Wilkes is GP and clinical research fellow at University of Sunderland and GP adviser for Infertility Network UK
Infertility Network UK
This is a national charity created by a merger between two former charities, CHILD and ISSUE. Infertility Network UK is the only UK-wide information and support network for couples with fertility problems.
Its functions include:
· Advice line
· Evening telephone counselling service
· Regional support groups and events
· Medical advisers
· Quarterly magazine
· Factsheets on a wide range of subjects
· Website providing access to news, chat forums and useful links www.infertilitynetworkuk.com
What I'm going to do now
Dr Ruckert responds to the answers to her questions:
· Expectation in infertility is often unrealistic but perhaps that hope is necessary to go through the process.
· I still have worries about initiating clomifene myself without USS guidance, especially as the CSM suggests a finite number of cycles.
· Semen analysis is also a difficult area without specialist input as the results are rarely conclusive and the question then is: 'How unlikely does that make me to conceive?'
Linden Ruckett is a GP in north London26>