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Probability diagnosis

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The couple:

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  • ageing

  • sexual technique incl. dyspareunia

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Female factors approx. (40%):

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  • ovulation disorders e.g. ovarian failure, PCOS

  • other causes amenorrhea or hypomenorrhea

  • tubal disease e.g. endometriosis

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Male factors (approx. 40%):

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  • defective sperm

  • anti-sperm agents e.g. cytotoxic, anabolic steroids

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Serious disorders not to be missed

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Infection:

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  • STIs → tubal or epididymal blockage

  • Pelvic inflammatory disease

  • Endometrial TB

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Tumours:

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  • Uterine fibroids/cancer

  • Pituitary or adrenocortical

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Other:

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  • Systemic illness

  • Cervical stenosis

  • Diet/obesity

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Pitfalls (often missed)

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Unreceptive cervical mucus

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Rarities:

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  • Anatomical congenital disorders e.g. uterine, Fallopian

  • Chromosomal abnormalities e.g. Klinefelter syndrome, Turner syndrome

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Masquerades checklist

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Depression incl. drugs

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Diabetes

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Drugs: various

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Thyroid/other endocrine: several incl. hyper/hypothyroid, prolactinaemia

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Spinal dysfunction

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Is the patient trying to tell me something?

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Consider psychosexual dysfunction incl. technique

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NB: unexplained 20–25%

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Key history

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In men: sexual function, past history incl. testicular problems e.g. mumps orchitis, undescended testes; medical problems e.g. diabetes, STIs, genitourinary surgery; occupational e.g. exposure to heat, pesticides; drugs e.g. chemotherapy, illicit agents, alcohol, smoking, antihypertensives. Frequency and timing of intercourse (both). In women: past history incl. previous fertility, obstetric, menstrual, STIs and PID, genitourinary surgery and abdominal surgery esp. appendicitis, peritonitis, abortion, IUCD use, body weight, drugs e.g. smoking, alcohol, OCP, anabolic steroids. Symptoms of ovulation and endometriosis

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Key examination

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Both: body habitus, general health, secondary sex characteristics, urinalysis.

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Men: external genitalia including testes (normal range 15–35 ml) and penis, PR.

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Women: genitalia and breasts, thyroid status, vaginal and pelvic examination.

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Key investigations

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Men:

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  • semen analysis

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Consider:

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  • FSH & LH

  • testosterone

  • sperm function tests e.g. antibodies

  • testicular ultrasound

  • chromosomal analysis

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Women:

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  • basal body temperature chart and cervical mucus diary

  • s. progesterone (mid luteal)

  • anti-Mullerian hormone

  • rubella status

  • transvaginal ultrasound

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Consider:

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  • thyroid status

  • s. prolactin

  • FSH and LH

  • coeliac antibodies

  • chlamydia test

  • hysterogram

  • hysteroscopy/laparoscopy

  • CT pituitary fossa

  • reproductive gene screening e.g. cystic fibrosis, fragile X

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