Clinical Reproductive Science

Michael Carroll

• Publisher: Wiley-Blackwell
• Year: 2018
• Print ISBN: 9781118975954
• eBook ISBN: 9781118977248
• Edition: 1
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

The comprehensive and authoritative guide to clinical reproductive science

The field of clinical reproductive science continues to evolve; this important resource offers the basics of reproductive biology as well as the most recent advance in clinical embryology. The author - a noted expert in the field - focuses on the discipline and covers all aspects of this field. The text explores causes of male and female infertility and includes information on patient consultation and assessment, gamete retrieval and preparation, embryo culture, embryo transfer and cryopreservation.

Comprehensive in scope, the text contains an introduction to the field of clinical reproductive science and a review of assisted reproductive technology. The author includes information on a wide range of topics such as gonadal development, the regulation of meiotic cell cycle, the biology of sperm and spermatogenesis, in vitro culture, embryo transfer techniques, fundamentals of fertilisation, oocyte activation and much more. This important resource: 

• Offers an accessible guide to the most current research and techniques to the science of clinical reproduction
• Covers the fundamental elements of reproductive science
• Includes information on male and the female reproductive basics – everything from sexual differentiation to foetal development and parturition
• Explores the long-term health of children conceived through IVF
• Contains the newest developments in assisted reproductive technology

Clinical Reproductive Science is a valuable reference written for professionals in academia, research and clinical professionals working in the field of reproductive science, clinical embryology and reproductive medicine.  

Section Three
Clinical Reproductive Science In Practice: IVF and Assisted Reproductive Technologies

18
Assessing the Infertile Couple

Narmada Katakam, Ruth Arnesen, Caroline Watkins, Bert Stewart, and Luciano G. Nardo

Introduction

Definitions

1. Infertility is defined as the inability to conceive after regular unprotected sexual intercourse for 12 consecutive months, in the absence of any known cause (NICE 2013).
2. Subfertility is defined as the inability to conceive due to reduced fertility. Clear understanding of the definitions of sub‐ and infertility is very important for the appropriate management of infertility (Gnoth et al. 2005).
3. Primary infertility is when someone has never conceived in the past and has difficulty conceiving now.
4. Secondary infertility is when someone has had one or more pregnancies in the past and has difficulty conceiving now.

Epidemiology of Infertility

More than 80% of couples conceive in the first year and circa 90% in the second year, with some age dependent differences (Dunson et al. 2004). The remaining couples may require some kind of fertility treatment to achieve a successful pregnancy (te Velde et al. 2000; Taylor 2003a).

Since 1991, 170 000 babies have been born as a result of in vitro fertilization (IVF) treatment in the UK, constituting almost 2% of all the newborns in the country (Human Fertilisation and Embryology Authority 2011). Infertility affects one in seven heterosexual couples in the UK, which equates to approximately 3.5 million people (Human Fertilisation and Embryology Authority 2010). These patients should be offered further clinical assessment and tailored investigations. However, earlier referral should be offered when the woman is aged 35 or over and there is a known cause or predisposing factor increasing the risk of infertility. Main reasons for infertility in the UK include male factors (30%), ovulation disorders (25%), unexplained (25%), tubal damage (20%), uterine or peritoneal factors (10%), and both male and female factors (40%). Some couples may have more than one cause (NICE 2013). Other reasons include uterine abnormality, endometrial factors, gamete or embryo defects, and pelvic conditions such as endometriosis, fibroids, and adhesions. Fertility assessments fail to identify an abnormality in up to 25% of infertile couples (Gelbaya et al. 2014).

The number of couples seeking help for fertility is constantly rising. Women delaying starting a family until their late 30s or even early 40s is a significant contributing factor to the changing face of fertility performance in developing countries.

The rate of spontaneous pregnancy amongst subfertile couples is less than the fertile population. Heterosexual couples should be seen together as the process affects both partners. Assessment should take individual needs, underlying medical problems, and treatment preferences into account. The patients should be given adequate information to be able to make well‐informed decisions about their management. Thorough assessment is recommended, to include history, clinical examination, and investigations (Kamel 2010) as outlined in Figure 18.1 and 18.2. Counseling is also an important part of the fertility assessment and should be offered to all patients seeking fertility treatment.

Figure 18.1 Flow diagram outlining initial assessment of the female patient including clinical history, physical examination, and screening. AFC, antral follicle count; AMH, anti‐Müllerian hormone; FSH, follicle‐stimulating hormone; HSG, hysterosalpingogram; HyCoSy, hysterosalpingo‐contrast‐sonography; IVF, in vitro fertilization; Lap & Dye, laparoscopy and dye test; LH, luteinizing hormone; PRL, prolactin level; TFT, thyroid function test; TVUSS, transvaginal ultrasound scan.

Figure 18.2 Flow diagram outlining initial assessment of the male patient including semen analysis. FSH, follicle‐stimulating hormone; ICSI, intracytoplasmic sperm injection; LH, luteinizing hormone; PRL, prolactin level; SSR, surgical sperm retrieval.

History Taking: Female Partner

General factors that reduce fertility in a couple include (Taylor 2003b):

• Woman aged over 35 years
• No previous pregnancy
• Trying to conceive for >3 years
• Infrequent sexual intercourse
• Woman’s body mass index (BMI) <20 or >30
• Regular use of recreational drugs
• Sexually transmitted infections
• Lifestyle factors including smoking in one or both partners, caffeine intake >2 cups of coffee per day.

As shown in Table 18.1, the causes of female infertility can be mainly subdivided into ovulatory disorders, tubal and peritoneal factors, cervical factors, and unexplained causes (Sanders and Debuse 2003). Detailed history from both partners usually indicates the underlying reproductive problem (Forti and Krausz 1998; Whitman‐Elia and Baxley 2001; Case 2003; Taylor 2003b). History taking should include details of age, duration of infertility, cervical smears, breast changes and milk‐like discharge (galactorrhoea), excessive hair growth with or without acne, hot flushes, recent weight loss or weight gain, and previous fertility treatment.

1. Menstrual history: age of menarche, cycle characteristics – frequency, duration, dysmenorrhoea, intermenstrual or postcoital bleeding. Review for any history of primary or secondary amenorrhoea. Women with regular menstrual cycles are very likely to be ovulating and should be reassured.
2. Obstetric history: previous pregnancies, if any, and its outcome, recurrent pregnancy loss, terminations, infection or puerperal sepsis.
3. Contraceptive history: previous use of contraceptives, any associated problems including lost coil, latest contraceptive methods and when last used. This is particularly relevant for medroxyprogesterone injections and combined pills as the return of fertility can be longer –up to 1 year in some cases.
4. Sexual history: frequency of intercourse, timing in relation to the cycle, use of vaginal lubricants, douching after sexual intercourse, dyspareunia, loss of libido, and history of any sexually transmitted infections
5. Medical history: diabetes, hypertension, thyroid disorder, cystic fibrosis, sickle cell disease, tuberculosis, and history of ovarian cysts. Enquire about rubella status.
6. Surgical history: appendicectomy, tubal surgery, pelvic surgery, laparotomy and bowel surgery, Caesarean sections, and cervical loop excision or conization.
7. Family history: consanguinity, diabetes mellitus, hypertension, and cancer.
8. Social history: occupation, diet, drug history including recreational drugs such as marijuana and cocaine, smoking, alcohol and caffeine consumption.

Table 18.1 Causes of and influences on female subfertility (Saunders and Debuse 2003).

Causes of Female ...

Table of contents

• Cover
• Table of Contents
• About the Editor
• Preface
• Section One: Reproductive Science
• Section Two: Clinical Reproductive Science
• Section Three: Clinical Reproductive Science In Practice
• Index
• End User License Agreement