Professor William Ledger
University of Sheffield

'We do not know all the answers.' In summarising infertility in endocrine disorders, it is important to note that the whole reproductive system depends on hormones; if certain hormones are lacking the system won't work.

The frequency of infertility has changed little in the last 20 years, although sperm quality appears to be falling, and women are deferring pregnancy because of careers. More couples are coming forward for help; in the past, older people were reluctant to ask for advice. Counselling, literature, support groups and erectile dysfunction nurses enable patients to be better informed and empowered. Among patients trying to conceive, 30% of couples succeed in the first month of trying, 90% within 12 months, and 95% within 2 years. Investigation is therefore usually considered when couples have been trying for 12-24 months.

Hormone levels can be altered in a variety of endocrine disorders. Most common is a rise in the level of Prolactin caused by a Prolactinoma. LH (Luteinising hormone) and FSH (Follicle-stimulating hormone) are switched off, and, as these are essential for conception, pregnancy cannot occur. This can be treated with drugs such as cabergoline. Alternative treatments for pituitary infertility include injecting Gonadotrophins intramuscularly, or wearing a small pump to deliver pulses via a needle under the skin.

Primary and secondary Amenorrhoea are major causes of infertility in women. Primary amenorrhoea can result from chromosomal defects such as Turner's syndrome, end organ failure, adrenal hyperplasia, delayed menarche or Kallman's syndrome; secondary disease may be caused by the Hypothalamus, weight, stress, drugs, pituitary tumours, Sheenan's syndrome, polycystic ovary syndrome, atrophy of the uterus by tubal or uterine disease, sexually transmitted diseases or pelvic TB. Polycystic ovary syndrome may occur in 20% of women; they will need help to conceive because of low LH / FSH. Drugs such as Bromocriptine, cabergoline, clomiphene or tamoxifen will induce menstruation.

Male infertility can be influenced by many factors which, in turn, affect Testosterone levels, e.g. cigarettes, marijuana, alcohol, cimetidine, sulphazalasine, spironolactone, steroids, anti-malarial preparations, and toxins such as DDT.

For diagnosis, the consultant needs to see both partners for physical examination and to discuss medical history. The following may be assessed: semen parameters, ovulation history, cervical mucus, tubal patency by laparoscopy, uterine condition by hysterosalpinography, follicle growth by ultrasound, luteal phase Progesterone, blood tests for chromosomes and hCG (human chorionic gonadotrophin), and post-coital tests.

Of males with Hypogonadism, most will respond to injections of testosterone to establish puberty and maintain sex drive, but will require LH / FSH injections to produce sperm. FSH and hCG are given two or three times a week for about 3-4 months; after this time sperm analysis is made and the drug dosage altered accordingly. Two types of drug are available: genetically engineered in the laboratory (recombinant), or from post-menopausal women's urine (reconstituted). Please don't be put off! Note also that it is the quality, not the quantity, of ejaculated fluid that matters. In addition, prostate enlargement in older men can cause 'retrograde ejaculation', where seminal fluid travels backwards into the bladder rather than out via the penis. This may cause the urine to be cloudy.

If no pregnancy occurs after a year, other options will need to be considered, perhaps donor sperm or IVF. Counselling may be necessary at this stage, as personal views vary considerably.

An enormous amount of help is available for men and women with infertility. Don't be put off by embarrassment, ask questions, be inquisitive. Help is out there!