Patient worried termination may have affected fertility
Elizabeth is 30, has been on the contraceptive Pill since she was 18 and has had several relationships in the past. She had a termination at 17. Her husband is unaware of this. They have been having regular sexual intercourse
for over six months but have failed to conceive. She is worried that her previous termination may have affected her fertility or that her husband may have a problem. Dr Tanvir Jamil offers advice.
What would be your initial approach?
Usually a couple should be seen together;15 per cent of couples have more than one problem. However, in view of Elizabeth's history it would be wise to get as much history from her as possible now: menstrual history, past contraception, previous pelvic infections, abdominal operations and sexual history. Tread carefully in future consultations when you see the couple together.
Reassure her that as long as there were no complications the termination should not affect her fertility. However, many women find infertility more difficult to handle if they have had a termination in the past.
One in six couples has problems conceiving. In many cases there is a high rate of spontaneous conception, especially in women under 35 with an 'infertility problem' of less than two years. Only 80-85 per cent of 'normal couples' conceive after a year of unprotected intercourse. The rest take another six to 12 months.
I would advise Elizabeth that as ovulation approaches they should refrain from intercourse for a few days to build up semen volume, then have lots of regular intercourse starting one to two days before ovulation and continuing for three to four days. An ovulation kit is helpful.
A basic history for the man should include age of puberty, sexual history, fathering of previous pregnancies, surgical history (such as hernia repairs, bladder surgery, testicular surgery), illnesses (such as mumps and venereal disease), drug therapy and alcohol intake.
Would you carry out a physical examination?
The woman should have a pelvic and abdominal examination and a general examination to exclude endocrine disorders such as hirsutism in polycystic ovarian syndrome (PCOS).
I would examine the man only if the semen sample is abnormal. I would look for penile abnormalities, varicocoeles and size of the testicles (normal 3.5-5.5cm by 2.1-3.2cm). I would do a rectal examination to exclude prostatitis.
Are there any times when you would refer immediately?
Yes, when the cause of infertility is obvious: for instance if the man has had testicular surgery or the woman has a history of PCOS and infrequent periods, or pelvic inflammatory disease.
If Elizabeth returns in six months will you refer?
She would probably be more anxious at this stage and referral would be the best option. Some basic tests can be done first.
· If periods are regular, confirm ovulation by mid-luteal serum progesterone (usually day 21 in a 28-day cycle).
· If she has very infrequent periods or amenorrhoea, she is unlikely to be ovulating, so check hormone profile (FSH, LH, TSH, testosterone and prolactin). PCOS is the commonest cause for anovulation (an elevated LH or testosterone is not invariable, but an ultrasound will show ovarian morphology).
A high FSH points to primary ovarian failure. Prolactin can be raised by stress and slightly by PCOS. A very high prolactin may indicate a prolactinoma. Repeat and if indicated refer to a neurologist possibly for a CT/MRI scan.
· Semen counts tend to fluctuate and low counts should be repeated after three to four months. If there are more than a million white cells/ml refer to a genitourinary clinic to screen for gonorrhoea and chlamydia.
· If all tests are normal and ovulation is occurring, the next investigation is to confirm tubal patency.
What needs to included in the referral letter?
· Duration of infertility and whether it is primary or secondary
· Woman's menstrual details, past medical history
· The man's medical history and whether he has fathered previous pregnancies
· Details of previous pregnancies, miscarriages, postnatal infections, pregnancies with the current partner
Ask Elizabeth if you may mention the termination in the letter. If she gives you her permission, highlight in bold that her husband is unaware.
What options will this couple have?
If Elizabeth has PCOS, she should be advised to lose weight if her BMI is over 28. If required, she can start clomiphene citrate, 50mg once daily on days two to six of the cycle or a progesterone-induced bleed. This should be initiated by a consultant as there is a risk of ovarian hyperstimulation. A recent article in the BMJ recommends use for no longer than 12 cycles possibly because of an increased risk of ovarian cancer1. Ovarian diathermy is also used to initiate ovulation in some patients.
If the sperm count is low or there is less than 25 per cent motility, they could try superovulation and intrauterine insemination
For severe oligospermia and azoospermia, they can try intracytoplasmic sperm injection. If no sperm is retrievable, donor insemination is an option. Other options include:
· In vitro fertilisation can be useful in male infertility or in tubal disease
· Laproscopic surgery, for example for endometriosis, salpingostomy
· Egg donation
· Embryo donation