Infertility — structured SAQ (15 marks)

(a) Definition and threshold (3 marks)

One mark per point, maximum three.

• NICE definition: infertility is defined in practice as the period of time people have been trying to conceive without success after which formal investigation is justified and possible treatment implemented.^[5]
• Threshold: if a woman of reproductive age has not conceived after 1 year of unprotected vaginal intercourse, in the absence of a known cause, offer both partners further clinical assessment and investigation; with artificial insemination, after 6 cycles. This couple, at 14 months, meets it.^[5]
• Earlier referral: offer specialist referral at presentation if the woman is 36 or over or either partner has a suspected or known clinical cause.^[5]

(b) Investigation of both partners (5 marks)

One mark per point, maximum five.

• Semen analysis: compare with WHO reference values: volume 1.4 ml or more; pH 7.2 or more; concentration 16 million per ml or more; total 39 million per ejaculate or more; total motility 42% or more; progressive motility 30% or more; vitality 54% or more; normal forms 4% or more. Repeat an abnormal result, ideally 3 months later.^[6]
• Ovulation: offer mid-luteal serum progesterone (day 21 of a 28-day cycle) to confirm ovulation even with regular cycles.^[6]
• Ovarian reserve: use maternal age as the initial predictor; AMH or antral follicle count predicts ovarian response for counselling about assisted conception, not spontaneous pregnancy.^[6]
• Tubes: hysterosalpingography to screen for tubal occlusion if no comorbidity is known (hysterosalpingo-contrast-ultrasonography where expertise exists); laparoscopy and dye if comorbidity is suspected.^[6]
• Uterus: do not offer hysteroscopy unless a uterine or endometrial abnormality is clinically suspected.^[6]

(c) Tests not to do and the male genetic tests (4 marks)

One mark for the tests not to do; three for the genetic tests.

• Do not: offer routine antisperm antibody testing; test sperm DNA integrity (fragmentation); routinely use post-coital testing of cervical mucus, which has no predictive value on pregnancy rate.^[6]
• Genetic tests: Y chromosome microdeletion in idiopathic azoospermia or a concentration under 1 million per ml; CFTR mutations in idiopathic suspected obstructive azoospermia or a vasal abnormality; karyotype in idiopathic azoospermia, and consider it with a persistent concentration under 5 million per ml; genetic counselling when a specific defect is found.^[6]

(d) Unexplained fertility problems (3 marks)

One mark per step.

• Try for 2 years in total with regular unprotected intercourse before treatment.^[8]
• Do not offer ovarian stimulation as stand-alone treatment.^[8]
• Then: consider up to 4 cycles of IUI with gonadotrophin stimulation before IVF, or offer IVF.^[8]