Infertility Note

Reason for Visit

• Primary Concern: Infertility

Presenting Issue

• Duration of Infertility: Trying to conceive (TTC) for 14 months without success.

• Primary Symptoms: Mild facial hirsutism and occasional acne; denies pelvic pain, dyspareunia, or galactorrhoea.

• Menstrual History: Oligomenorrhoea; irregular cycles ranging 35–50 days, bleed duration 5 days, normal flow, no IMB or PCB. LMP 5 weeks ago.

• Partner’s Fertility Status: 34 yo male, fit and well, no previous children, no known history of testicular trauma, mumps, or STI.

Past Medical History

• Gynaecological History: Up-to-date cervical screening (HPV negative 14/05/2023). No history of PID, endometriosis, or STIs. Stopped combined oral contraceptive pill (COCP) 15 months ago.

• Obstetric History: Nulligravida (G0 P0).

• Chronic Conditions: Mild asthma, well-controlled.

• Medications: Folic acid 400 mcg PO OD, colecalciferol (vitamin D3) 1,000 IU PO OD, salbutamol 100 mcg/dose inhaler 1–2 puffs PRN.

Lifestyle Factors

• Sexual History: Regular unprotected vaginal intercourse 2–3 times/week; no erectile or ejaculatory dysfunction reported by partner.

• Lifestyle: Non-smoker, alcohol 2–4 units/week, caffeine 1 cup of coffee daily, works as a primary school teacher (moderate stress).

• Weight and Nutrition: Weight 78 kg, Height 1.65 m, BMI 28.7 kg/m². Balanced diet, attempting calorie deficit.

Physical Examination

• General Appearance: Well, alert, mildly elevated BMI, mild terminal hair growth on chin. BP 118/74 mmHg, HR 68 bpm.

• Abdominal Examination: Soft, non-tender, no masses or organomegaly palpable.

• Pelvic Examination: Normal external genitalia. Speculum: healthy cervix, no discharge. Bimanual: anteverted uterus of normal size, mobile, no adnexal tenderness or masses, no cervical motion tenderness. High vaginal and endocervical swabs taken.

Initial Diagnostic Work-Up

• Investigations Ordered:

  • Blood Tests: Day 2–5 FSH, LH, oestradiol; serum total testosterone, SHBG, prolactin, TFTs, rubella immunity, HbA1c. Mid-luteal progesterone (7 days prior to expected menses).

  • Ultrasound: Transvaginal pelvic ultrasound (TVUS) to assess ovarian morphology (query polycystic ovaries) and endometrial thickness.

  • Partner Evaluation: Advised partner to book with own GP for semen analysis.

Assessment

• Working Diagnosis: Primary subfertility secondary to suspected anovulation / polycystic ovary syndrome (PCOS).

• Differential Diagnosis: Hyperprolactinaemia, thyroid dysfunction, tubal factor subfertility, or male factor subfertility.

Treatment Plan

• Immediate Management:

  • Lifestyle Modifications: Advised weight reduction (aiming for 5–10 % weight loss to help restore spontaneous ovulation), regular aerobic exercise, and alcohol cessation while TTC. Continue regular intercourse every 2–3 days.

  • Medication: Continue folic acid 400 mcg PO OD and colecalciferol 1,000 IU PO OD. No ovulation induction initiated in primary care.

• Further Evaluation:

  • Referral: Routine referral to NHS Secondary Care Fertility Clinic once baseline bloods, TVUS, chlamydia screening, and partner's semen analysis results are available.

  • Additional Testing: NAAT endocervical swab sent for Chlamydia trachomatis and Neisseria gonorrhoeae prior to any future uterine instrumentation/hysterosalpingography (HSG).

Next Steps

• Follow-Up Appointment: Review in 6 weeks (or sooner once blood and TVUS results return) to discuss findings and finalise specialist referral.

• Referral: Pending completion of baseline primary care work-up as per local ICB subfertility pathway.

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Signature

Dr Sarah Jenkins

General Practitioner (GMC: 7482910)

Elmwood Medical Practice, 14 High Street, Bristol, BS1 2AW | Tel: 0117 496 0123

Date: 24/10/2024