Secondary Sub-Fertility: Past Medical and Surgical History - Essay Example

Running head: SUBFERTILITY Subfertility Halima Tabani [Institute's 12th May 2009 Subfertility Case History: a couple requestingassistance with secondary sub-fertility Demographics: Age of the female partner: 38 years Age of the male partner: 41 years Ethnicity: Asian Presenting complains: Inability to conceive despite regular unprotected intercourse since the last 6 years History of presenting illness: According to the couple they have been married for the last 16 years. They have had one child who was born 14 years back but had unfortunately passed away due to diarrheal disease in Pakistan. Since the last 6 years, the couple has been unsuccessful in conceiving a child despite regular, unprotected sexual intercourse. Past Medical and Surgical History: The woman is status-post (S/P) thyroidectomy, which was done for the treatment of Goiter. She is currently taking thyroxine for hypothyroidism. Moreover, she also reports to having fainting spells in the past for which she was investigated and was prescribed medications for the relief of symptoms. She is currently taken digoxin and calcichew D3. The male partner has a history of schizophrenia and is currently seeking treatment for it. The drugs he is taking include depot injection and oral procyclidine, chlorpromazine and lorazepam. For the current problem, the couple has visited a GP who has prescribed clomifene which was to be taken from day two up to day five of her menstrual cycle for last three months in order to help with ovulation induction. Family History: Was not explored for any similar problems regarding fertility or any other general medical conditions. Menstrual History: The woman reports having regular menstrual cycles of 4/28 days with normal flow. She has no complains of dysmenorrhea or intermenstrual bleeding. She has had regular cervical smears which were reported to be normal. The woman denies the use of any form of contraception. Sexual History: The couple report having regular, unprotected sexual intercourse. The frequency of intercourse is atleast thrice a week. There are no complains of dysparunea, post coital bleeding or any other problems. Past Obstetric History: The woman has been pregnant once almost 14 years back. She has never conceived after that. She does not report having any miscarriages or undergoing any terminations of pregnancy. Social History: The woman did not have any addictions or allergies. The male partner admitted to being an ex-smoker who had quit 10 years back. He did not report any use of alcohol or any other psychoactive substances. Findings on Examination: The woman had a BMI of 21. The blood pressure taken was normal. Pelvic examination done was unremarkable and did not reveal any signs of an obvious pathology. In order to rule out any ongoing infections, swabs were taken and sent for laboratory testing. Differential Diagnosis: Keeping the history and examination, which did not reveal any particular findings, in view, a provisional diagnosis of secondary subfertility was made. This could have several different causes both on the part of the male and the female. Any abnormality in the female genital tract, ranging from problems in ovulation to those in implantation can lead to subfertility. Similarly, amongst males, problems with ejaculation, sperm count, number and quality can lead to subfertility. In order to determine which of the causes was present in this couple, further investigations were imperative. Investigations ordered and their results: In order to elucidate a specific cause for the subfertility a number of tests were ordered. For the woman, rubella, FBC, day 3 FSH, LH, testosterone, Sex hormone binding globulin, and day 23-progesterone were ordered. For the male, a semen analysis was ordered. Both the partners were counseled about how to give samples and what purpose these tests were going to serve. The couple was asked to return for follow-up with the results of the investigations in 10 weeks. The results of the investigations revealed the following: Rubella -positive, HB 14.0, MCV-84, FSH-5.6, LH-1.7, Testosterone - 0.8, SHBG - 20, SWABS-Negative for any infection TSH 27.3, T4-13.6 With regard to the semen analysis for the husband, no results were available and the wife reported this was due to the husband having a dry ejaculate. On further questioning, it was revealed that the husband was having this problem for the past 2-3 years and had never been investigated for it. Management Plan: After the appropriate investigations were undertaken, the couple was referred to a specialist sub-fertility clinic. Clinical Course: The feedback from the local consultant revealed that the patient had been reviewed by the consultant 18 months ago and was advised against pregnancy. This was based on the reason that the woman suffered from a mild degree of mitral valve stenosis. Keeping in view the woman's age and her general medical condition it was recommended that the lady should avoid pregnancy. Moreover, on husband's examination, it was found that he had small testes. Keeping this factor in mind, it was suggested that if the couple did decide to have a child, they should opt for sperm donor insemination. For further workup of breathlessness and the suspicion of mitral valve stenosis, the woman was referred to a cardiologist who after the appropriate investigations, including an exercise tolerance test, confirmed that the woman was suffering from mitral valve stenosis with trivial regurgitation, moderately dilated Lt Atrium but good systolic LV function and no evidence of aortic valve disease or pulmonary hypertension. The cardiologist recommended that if the woman decided to undergo pregnancy, then she should be vigilantly followed by an obstetric cardiologist and monitored for any complications such as cardiac dysrhythmias. Moreover, in case any such complications arose, anticoagulation was advised. Subfertility - Epidemiology and Pathogenesis The term subfertility refers to "the inability to conceive after twelve months of regular, unprotected intercourse, or the occurrence of more than two consecutive natural miscarriages or stillbirths (Vessay, 1991, p. 397)." In general, any form of decreased fertility whereby unwanted non-conception persists for long time duration can be termed as subfertility (C.Gnoth, E.Godehardt, P.Frank-Herrmann, K.Friol, Tigges, & G.Freundl, 2005, p. 1144). Subfertility can be either primary whereby a woman has never conceived or secondary whereby a couple has been unable to produce the number of children they require (Evers, 2002, p. 151). The issue of subfertility is fairly common in today's society affecting almost 15% of the Western population. The magnitude of the burden is fairly high and studies have shown that almost one out of every six couples have to seek specialist medical attention or advice regarding fertility problems (Evers, 2002, p. 151). Subfertility can be caused by a variety of factors affecting either the male or the female partner and are thus termed as male factors and female factors. Studies have shown that the most common causes of infertility can be attributed to female factors, approximately 20% of the cases of subfertility can be attributed to male factors exclusively and almost 27% to a combination of both male and female factors. (Wai Yee Wong, Thomas, Zielhuis, & Steegers-Theunissen, 2000, p. 435). For the purposes of simplification, clinicians have classified the causes of fertility into five broad subgroups viz. male subfertility, disturbances in ovulation, defects in spermatozoa-cervical mucus interaction, tuboperitoneal disorders, and unexplained subfertility (Evers, 2002, p. 153). The male factors which can lead to infertility include absence of testicular tissue, as observed in anarchism; abnormalities in sperm production which can be attributed to various factors such as age especially greater than 55 years, genetic causes e.g. Klinefelter syndrome, nutritional deficiencies, varicocele, infections and environmental agents such as smoking, drug abuse, temperature and medications; Impaired sperm transport due to reasons such as epididymal blockage or ejaculatory failure and disturbances in sperm-oocyte fusion which can be brought about by the presence of abnormal egg-binding proteins (Wai Yee Wong, Thomas, Zielhuis, & Steegers-Theunissen, 2000, p. 437). Ovulation disturbances account for approximately 20% of all cases of subfertility (Adamson & Baker, 2003, p. 169). The most important factor which rules out any ovulation disturbance is the presence of regular menstrual cycles. Problems which can lead to anovulation or hypo-ovulation include polycystic ovarian syndrome which is present in almost 70% of the cases, endocrine abnormalities such as hyperprolactinaemia, age-related ovulation dysfunction and premature ovarian failure. Other rare causes include congenital adrenal hyperplasia and extremes of weight i.e. excessive obesity or excessive weight loss due to problems such as anorexia. Another category of etiologies which can lead to subfertility is tuboperitoneal disorders. Tubal factors alone account for almost 35% of all causes of subfertility (Adamson & Baker, 2003, p. 170). The different pathologies which come under this category include hydrosalpinx, salpingitis, PID, salpingitis isthmica nodosa, adhesions, endometroisis, etc (Adamson & Baker, 2003, p. 170). Moreover, problems in the uterine cavity such as anatomical defects and luteal phase deficiency may also lead to subfertility (Adamson & Baker, 2003, p. 171). Moreover, in a minority of patients there may be defects in the spermatozoa-cervical mucus interaction which can be due to factors such chronic infections which can lead to a poor quality of the cervical mucus plug (Adamson & Baker, 2003, p. 171). In addition, in about 5-10% of the cases, there may be no cause found despite exhaustive investigations and this is termed as unexplained subfertility (Adamson & Baker, 2003, p. 173). With regard to the above mentioned case, there were several aspects of management of this couple which merit discussion. Firstly, the GP started the patient on Clomid, which was based on the assumption that there was a problem with ovulation, without any investigations to rule out other causes of subfertility. As discussed above, subfertility can be caused by a multitude of reasons and amongst these, only 20% can be accounted for by ovulation disturbances. The most important factor which rules out any ovulation disturbance is the presence of regular menstrual cycles. Studies suggest that cycles which last for 22-35 days are usually ovulatory, and if accompanying premenstrual symptoms of breast tenderness and bloating, etc are present than ovulation disturbances are highly unlikely (Adamson & Baker, 2003, p. 169). The patient in this case had no menstrual irregularities and had normal, regular menstrual cycles, which points towards normal ovulation. Moreover, almost 20% of the cases of subfertility can be attributed to male factors exclusively (Wai Yee Wong, Thomas, Zielhuis, & Steegers-Theunissen, 2000, p. 435) and therefore, this arena should also be explored before making a presumptive diagnosis and starting treatment. Thus, in this case, the GP should have first further investigated and ruled out other causes of subfertility before starting the woman on Clomid. Secondly, the woman in question is suffering from mitral valve stenosis. Studies have shown that pregnancy in women with mitral stenosis carries several risks. Almost 25% of the women with mitral stenosis develop heart failure during pregnancy and in women with severe mitral stenosis, the risk of mortality during pregnancy varies between 5-15% (Ramin & III, 1999, p. 108). The most common symptoms of mitral stenosis which can be observed during pregnancy include dyspnea or difficulty in breathing which occurs as a consequence of pulmonary hypertension and pulmonary edema, orthopnea and paroxysmal nocturnal dyspnea which occurs in recumbent position due to redistribution of the blood from all the dependant parts of the body into the lungs thus increasing the fluid load, cough, which is more pronounced at night and hemoptysis which may occur due to the rupture of an existing anastomosis between the bronchial and pulmonary veins (Ramin & III, 1999, p. 107). Thus, adequate fluid intake and limiting salt intake are important in preventing pulmonary edema (Mendelson, 2003, p. 68). Moreover, sudden symptoms of heart failure may manifest during pregnancy. Long standing mitral stenosis can lead to left atrial enlargement which can cause symptoms such as premature atrial contractions, paroxysmal atrial tachycardia, atrial flutter, and atrial fibrillation (Ramin & III, 1999, p. 107). Atrial fibrillation may lead to thromboembolic phenomenon since pregnancy is a hypercoagulable state in itself (Mendelson, 2003, p. 69). It has been elucidated that ventricular filling time is an important variable with determines the outcome in women with mitral stenosis, since such women have a fixed cardiac output and tachycardia due to any cause leads to an impairment in this variable, thus leading to adverse outcomes (Ramin & III, 1999, p. 108). There are a number of factors during pregnancy which can lead to tachycardia and these include pain, hypertension, anemia, blood loss during delivery and a high susceptibility to infections (Ramin & III, 1999, p. 108). Thus, since this patient has mitral stenosis she is predisposed to all these adverse outcomes and risks if she decides to go ahead with the pregnancy. Schizophrenia is a mental disorder which carries with it significant social and functional impairment. Moreover, there is also considerable social stigma attached with this disorder, particularly amongst certain cultural groups such as the Asians. In this case, the male partner is schizophrenic. This raises the concern of the risk of schizophrenia in the offspring if the woman conceives. Research has proven that a genetic basis for schizophrenia exists and thus a positive family history is a risk factor for the development of schizophrenia (Mortensen, et al., 1999, p. 603). A review of family studies showed that there was 4.8% risk of developing schizophrenia if a first blood relative had the disorder (Kendler & Dlehl, 1993, p. 262). Similarly, Mortnesen et al. (1999) while studying a Danish cohort of patients elucidated that there was a 7.2 times relative risk of an offspring developing schizophrenia if the father had the disease (Mortensen, et al., 1999, p. 603). Thus, when the couple is being counseled regarding fertility treatment, they should also be informed about the risks of schizophrenia in the offspring. Another aspect of the father having schizophrenia is the use of psychotropic drugs by the father for the treatment of this psychiatric condition. Psychotropic agents have been shown to cause several sexual side effects such as decreased sexual drive, erectile dysfunction and premature ejaculation (Compton & Miller, 2001, p. 91). The sexual dysfunction hence caused can indirectly lead to subfertility. Moreover, most typical and atypical antipsychotics lead to hyperprolactinaemia. This may lead to impaired gonadal function and hence lead to subfertility. Moreover, the loss of pulsatile GnRH secretion subsequent to the excessively high levels of prolactin, impairs the processes of steroidogenesis and spermatogenesis (Compton & Miller, 2001, p. 98). Thus, psychotropic medications can lead to subfertility both directly via effects on the reproductive function and indirectly by causing sexual dysfunction. A minor lapse which occurred during the management of this couple was that they were referred to the specialist before consult was taken from the psychiatrist and the cardiologist. As was revealed later during the course of management, the cardiologist deemed the condition of the woman as inappropriate to undergo pregnancy as it would involve the risks discussed above which would require vigilant monitoring under the care of an obstetric cardiologist. Moreover, the male partner was suffering from schizophrenia. This has several implications with regard to the decision regarding pregnancy. The foremost step should have been to determine what is the psychiatric condition of the patient currently and is any deterioration expected, by a psychiatrist. Since schizophrenia causes significant functional impairment, before deciding to produce an offspring, it is imperative for the parents to determine with the help of the psychiatrist to determine the impact this disorder would have on the child and whether the father is physically, emotionally and economically well enough to support the child. Moreover, the parents also need to be counseled about the risk of schizophrenia in the offspring if the father is affected before conception. Keeping all these points in view, it was imperative to obtain a comprehensive psychiatric evaluation of the father and a cardiology work up of the mother before referring them to the specialist as both these factors may influence the couple's decision to seek treatment for subfertility. With regard to the treatment plan for this couple, apart from donor insemination, there are several other options for this couple. Several new advancements have been made in the treatment of male factor infertility. These include novel micromanipulation methods and sperm aspiration techniques which have led to the development of methods such as Testicular Sperm Aspiration (TESA) and Microscopic Epididymal Sperm Aspiration (MESA). Sperm extraction using these methods can help in using methods such as IVF, ICSI, etc (Meirow & Schenker, 1997, p. 133). Another option for this couple is adoption. However, there are certain issues regarding adoption. These include the medical condition of the father and the mother, both of which are not optimal. Of more concern is the psychiatric disorder that the father is suffering from which limits his functionality and thus raises the issue that whether the father would be physically, mentally and financially able to bring up and support the child. The decision to choose the type of treatment is entirely up to the couple as dictated by the bioethical principle of autonomy which refers to "the capability and right of patients to control the course of their own medical treatment and participate in the treatment decision-making process (Scension, 2007)". The physician's role is to assist the individual's in making their decision by explaining them all the options available, clearly stating their risks and benefits according to the principle of informed consent. While choosing the type of treatment several ethical issues arise. These include issues regarding relationships, conflicts regarding biological and surrogate parenthood and religious and morality issues which question the use of egg/sperm from someone other than one's partner (Shanner & Nisker, 2001, p. 1590). In this case, the couple was offered the option of donor insemination. This may be correct from the medical point of view but may raise several ethical and moral issues for the parents especially keeping in mind their cultural background i.e. Asian. Thus, it is a physicians responsibility to keep in mind the cultural and religious background of the patients and also the ethical considerations associated with each treatment option before recommending a specific option for a couple. The management of this case provided several learning opportunities and involved various aspects of patient handling. Handling this case underscored the importance of patient counseling in clinical practice and it helped me learn how to counsel patients on sensitive issues. Moreover, from the bioethical point of view, this case was a perfect example of the patients' autonomy and right to make their own decisions. It also provided an opportunity for me to learn to what role doctors can play in helping patients make their decisions and to what extent should they intervene. In addition this case provided me an opportunity revisit several topics such as the causes of subfertility and its management and also helped me identify several new learning issues such as the most recent techniques for assisted reproduction and the various ethical issues associated with assisted reproduction. However, there were certain lapses and shortcomings in patient management which occurred in this case. Firstly, a further exploration of the family history and the past obstetric history (e.g. details of the previous pregnancy, was it a natural conception or assisted one, mode of delivery, pregnancy related complications, etc) as it would have implications in devising the management plan for this couple. Moreover, the male partner should have also been properly examined and evaluated and the arena of male factor infertility should have been further explored before referral to specialist for the treatment options. Similarly, the cardiology and psychiatry consults should have been taken before the referral. In conclusion, management of this case was a learning experience. Managing this case helped me understand the principles of patient handling more effectively and a reflection and identification of my shortcomings will help me change my clinical practice and prevent me from repeating similar errors in the future. References Adamson, G. D., & Baker, V. L. (2003). Subfertility: causes, treatment and outcome. Best Practice & Research Clinical Obstetrics & Gynaecology , 169-185. C.Gnoth, E.Godehardt, P.Frank-Herrmann, K.Friol, Tigges, J., & G.Freundl. (2005). Definition and prevalence of subfertility and infertility. Human Reproduction , 1144-1147. Compton, M. T., & Miller, A. H. (2001). Sexual Side Effects Associated With Conventional and Atypical Anti p s ychotics. Psychopharmacology Bulletin , 89-108. Evers, J. L. (2002). Female subfertility. Lancet , 151-159. Kendler, K. S., & Dlehl, S. R. (1993). The Genetics of Schizophrenia: A Current,Genetic-Epidemiologic Perspective. Scizophrenia Bulletin , 261-285. Meirow, D., & Schenker, J. G. (1997). The Current Status of Sperm Donation in Assisted Reproduction Technology: Ethical and Legal Considerations. Journal of Assisted Reproduction and Genetics , 133-140. Mendelson, M. A. (2003). Pregnancy in patients with obstructive lesions: aortic stenosis, coarctation of the aorta and mitral stenosis. Progress in Pediatric Cardiology , 61-70. Mortensen, P. B., Peders, C. B., Westergaard, T., Wohlfahr, J., Ewald, H., Mors, O., et al. (1999). Effects of Family History and Place and Season of Birth on the Risk of Schizophrenia. The New England Journal of Medicine , 603-608. Ramin, S. M., & III, L. C. (1999). Mitral Valve Disease in Preganancy. Primary Care Update in Obstetrics and Gyneacology , 106-110. Scension. (2007). Autonomy. Retrieved May 12, 2009, from Health Care Ethics: http://www.ascensionhealth.org/ethics/public/issues/autonomy.asp Shanner, L., & Nisker, J. (2001). Bioethics for clinicians: Assisted reproductive technologies. Canadian Medical Association Journal , 1589-1685. Vessay, E. G. (1991). The prevalence of subfertility: A review of the current confusion and a reprt of two new studies. Obstetrical & Gynecological Survey , 397-403. Wai Yee Wong, M., Thomas, C. M., Zielhuis, J. M., & Steegers-Theunissen, R. g. (2000). Male factor subfertility: possible causes and the impact of nutritional factors. Fertility and Sterility , 435-442. Read More