Reproductive health in general practice: opportunistic AMH, endometriosis, and when to refer

Fertility specialist

The Otter file does not state a speaker name. The clinic context as spoken: Pindara; Queensland Fertility Group for fertility preservation; Queensland For Women (Tugan) for dedicated gynae and obstetric scans and HyCoSy. No name is invented here.

Discuss AMH opportunistically — from about 25, earlier if endometriosis

The opening line of the night was the one to take home. You should be discussing AMH with all reproductive-age women, opportunistically. If you are not happy to order it, send them and the specialist will. The point is the conversation. They are finding so many young women with low AMH. If you do not have the conversation, they cannot do anything with the information.

From what age? Twenty-five, as a starting point. Earlier if you already know the ovaries are under threat. She described a 22-year-old with stage 3 endometriosis and two of the worst rectovaginal / pararectal nodules she had seen — shocking even to her. In that woman she has already ordered AMH, and she will sit with the result. If it is low: do we act now, or do we repeat? The published data sit from 25 years, so a 22-year-old’s result can still be “coming up.” Acting is one decision. Starting the conversation is the other, and it is the one GPs own.

If AMH is low and she wants fertility preservation, endometriosis is already a reason not to delay that discussion.

QFW scans and HyCoSy, not a generalist film

Asked what scan to use, including in young women of 19 to 20, the answer was specific. She uses Queensland For Women (QFW) at Tugan. Two things that differ from everywhere else, as she listed them:

• only female sonographers
• reports by obstetricians with subspecialty training, and they only look at gynae and obstetric scans

Contrast with Queensland X-ray / Q-scan: those reporters look at brains, livers, hearts — everything. Gynae is not their bread and butter. If she gets an abnormal scan from Q-scan, she will often repeat it at QFW before acting.

QFW also does HyCoSy — assessment of the tubes and the uterine cavity with dye. It is uncomfortable, especially for women with endometriosis. Warn them. There is a dedicated endometriosis assessment with a separate item number. A gynae scan, an endometriosis assessment, and a HyCoSy are not the same tape.

Cost: “not cheap.” Her practical line: if she is going to repeat an abnormal film at QFW before laparoscopy anyway, sometimes it is better to do the dedicated study once. Jackie Chu is the main director there; they will come out and see the patient if needed. The fertility team itself: Pindara, happy to see people.

Pelvic pain: never too early, start hormones, trial and error

Is there such a thing as too early to investigate symptoms? No.

Always start hormonal management if they will have it. Continuous pill, so you try to avoid a bleed. If they have done that and still have symptoms, that is the next conversation — not “wait a bit more.”

Favourite pill? No single favourite. It is trial and error, and there are enough types that you are bound to find one if the patient gives you patience.

What she is actually using: she likes a low-dose levonorgestrel combined pill (“Levlen” as spoken) because the run-of-the-mill dose fixes a lot of problems. She is using a lot more Yasmin now. They are on the PBS. There is evidence about bone mineral density with lower-dose oestrogen not being as good as 30 micrograms, so she tends to use the higher oestrogen doses in young women.

Infertility: one in six, and refer early when the picture is already wrong

One in six Australian couples will need some sort of intervention and will meet infertility. Primary: never had a pregnancy. Secondary: after a pregnancy, regardless of that pregnancy’s outcome.

Early referral if they are over 35. Also refer early for endometriosis, abnormal uterine bleeding, menorrhagia, intermenstrual bleeding, pull-up on skin (as spoken — treat as “anything on the skin that worries you” rather than inventing a dermatology label), anything you are worried about, and anyone who is simply not coping with repeated negative tests. Some women need a conversation and to know their options more than they need another six months of trying.

Male prompts to refer early: ejaculation problems, type 1 diabetes, undescended testes, any masses or cysts in the testes.

What to check if you are sending them away to keep trying

The classic GP question: they have been trying six months, they are under 35 — send them away, keep trying, reassure?

A lot of couples will conceive if they continue. That is not the whole sentence. If they have come to you, make sure things are normal first. Karyotype is something you might not order routinely. If they come back with their first pregnancy as a miscarriage, they will never forget that you sent them away without looking.

Her list if you are going to say “keep trying”:

• karyotype
• AMH
• thyroid
• prolactin
• hormones
• HbA1c, especially if PCOS
• for him: semen analysis and karyotype

Tubes: HyCoSy at QFW, or HSG (X-ray), or laparoscopy. If someone is coming with infertility and symptoms, she is going to laparoscopy, and she can assess the tubes then. If they want IUI without a laparoscopy, assess the tubes first — otherwise you are putting good sperm into a system you have assumed is patent, and they will not forgive a later blocked-tube surprise. IVF cares less about tubes because you are putting an embryo into the cavity. You still want no polyps.

Cases as taught: low AMH, missed bowel endometriosis, hypo-hypo, vasectomy reversal

Thirty-three, same-sex couple, AMH 1.7, incomplete excision

A 33-year-old in a same-sex relationship, partner already has two children from a previous relationship, now wanting a baby. Baseline as she listed it: FBC, chem 20, thyroid, vitamin D, iron, infectious diseases, varicella and rubella up to date, then AMH. AMH on referral was 1.7. Age 33. That is already “oh dear.”

She had had a laparoscopy in Canberra. She believed she had had complete excision. The notes did not read that way: ablation of some endometriosis, an endometrioma probably removed, only one specimen. Not complete excision. Symptoms were worsening.

She wanted to try first. The specialist did not want to touch remaining ovarian endometriosis and burn more reserve. A couple of IVF rounds: about three eggs each time, about one embryo from three eggs. They talked about changing sperm donor because endometriosis can hit egg quality; she did not want to, because the donor was the same as the other children’s father. Adjuncts named: CoQ10, melatonin, DHEA — “fertility booster,” not a fix. Three rounds, still no pregnancy. Back to laparoscopy. There was a huge bowel nodule — missed, not grown in two years. The conversation is now complete excision, possibly a bowel resection, combined with colorectal, about three hours, because she has terrible symptoms (cannot run). Embryos already banked. Watch this space — not an outcome invented here.

The teaching point for GPs: “complete excision” on a patient’s retelling is not always complete excision. Bowel nodules get missed. Low AMH plus endometriosis is a reason to be precious about remaining ovary.

Oligomenorrhoea, hypo-hypo, failed transfers, silent endometriosis

Next woman: oligomenorrhoea then amenorrhoea. Full work-up. Pure hypothalamic (hypo-hypo). These patients stimulate quite well once you get them started. They do not do very well on IUI. Ovulation induction usually does not work. IVF is the usual path. One round, several eggs, embryos frozen, first transfer a miscarriage, two transferred next, still no pregnancy.

Failed transfers make her think endometriosis even when the woman is asymptomatic, and make her think PGT so you are not calling it recurrent implantation failure unless biopsied-normal embryos are failing. Most of the time it is the embryo, not the cavity. They biopsied, laparoscoped in between, and found endometriosis and an adenomyoma, plus a large nodule. Excision of mild to moderate disease improves IVF success — she said it twice so it would stick.

Mechanism as she taught it: distorted anatomy (tubes pulled, ovary stuck to side wall, egg ovulated nowhere near the tube, monthly pulling pain); inflammatory cytokines hitting egg and embryo quality; adenomyosis hitting implantation because the same inflammatory story is in the lining. She needed downregulation — hormones shut off for three months (Zoladex or Synarel, “whatever your choice is”) — plus PGT-normal embryos. Now pregnant, nine weeks. Long road: failed transfers, PGT, laparoscopy, downregulation. Anxious. Every visit she gets a scan first so she can see a heartbeat.

Vasectomy reversal, two years, no sperm

A 34-year-old in a second relationship. Partner also in a second relationship, both young, both already parents. He had a vasectomy, then a reversal. She met them two years after the reversal. Still not pregnant. First question: have you checked the semen? There was no sperm.

Named local resources as spoken: Neil Smith as the go-to for male work; Gary Swift (her partner) also does TESA — testicular sperm aspiration, used with ICSI. If the vasectomy is more than about five years old, Neil’s line (as she recalled it) is to think TESA, not only reversal. People advertise reversals. The counselling that sperm quality may not be enough for spontaneous conception is not always there. Two years of trying into a zero sperm count is two years you do not get back. There had been some sperm initially, then it stopped — granuloma or similar, who knows when. Non-fertility clinicians can see “sperm present” and call it a win. Presence is not the same as sperm you would want to find an egg. TESA sperm is for ICSI only — pick the sperm up and put it in. Fresh is better. Same day as egg pickup, both under general anaesthetic, embryos made that day.

AMH 0.3 at 30 — and why the GP conversation exists

Another woman, 30, same-sex relationship, AMH 0.3, and luckily she already knew. That is the point of asking early. She also sees a lot of post-cancer patients. Fertility-preservation conversations are better than they used to be, but not universal. If someone is starting chemo and nobody has talked about freezing eggs or sperm, ring QFG (Otter: QFD). They can usually get a cycle in before chemo. Hospital clinics often make that call; GPs can too.

A 23-year-old in the Navy, lived in WA, sarcoma of the thigh, chemo-radiation, AMH also 0.3, FSH above 15. That FSH means the body is already shouting and the ovary is not answering — even replacing FSH is not predictable. Hard conversation. Poor stimulation odds.

Contrast: a young woman with low AMH who kept ovulating good-quality eggs intermittently and conceived spontaneously — including after a failed freeze-everything cycle, then a trip to Europe and a second spontaneous pregnancy. The line she wanted in the room: a low AMH has the same chance of pregnancy each cycle as a normal AMH. What she has lost is the number of cycles left. At 23 she is not going to bleed until 50. Once upon a time we called that premature ovarian insufficiency when the bleeds stopped. Now you can see it coming.

Young plus low reserve plus good-quality eggs is more reassuring than low reserve plus older age.

Repeating AMH, the pill, Mirena, and antral follicle count

Do you repeat AMH? Yes, if they are not ready to preserve or not ready for a baby. It is a trend.

• Three-monthly if they had a low result on the combined pill and you have taken them off it (condoms in the meantime if they agree).
• Otherwise about six to twelve months, tighter if they are older.

Combined pill can falsely lower AMH. Mirena does not. You can still draw AMH on the pill — you just interpret it differently, and you repeat off the pill if they want the real number.

Antral follicle count is the ultrasound version of reserve, day 1 to 10. She would rather have an AMH, because AFC depends on who is scanning. She can do AFC herself if she sees them in that window.

Carrier screening: one rebate, use it well

A 35-year-old trying for 18 months, regular cycles, no menorrhagia, no dyspareunia, completely asymptomatic — right on the referral cusp. At 35 you could have referred earlier; this woman may not have wanted it.

Day-21 progesterone 70: ovulating. Semen normal. Karyotypes. Then genetic carrier screening, which she flagged as a whole topic of its own.

The three-gene free screen is not the best test. You only get one rebate. If you order the three-gene panel and they later need the expanded panel, they have already used the rebate and then pay about $700 out of pocket, whereas they could have paid about $400 extra for the better test first. Expanded panel: on the order of 700 genes, and a better cystic fibrosis gene test. Sullivan Nicolaides, QML, Virtus — all do these. She uses Virtus. She offers it to everyone she sees for fertility. Not everyone wants it. Donor-sperm recipients: if the donor carries a gene, make sure the recipient does not carry the same one. Relative to the cost of making a baby, most of her patients will pay for the expanded panel. Do not spend the only rebate on the thinner test if they are heading into fertility care anyway.

A “blocked” HyCoSy that was spasm — and silent deep endometriosis

That same 35-year-old had a tertiary-level ultrasound and HyCoSy — not at QFW, as a side note. They could not pass the catheter. The report said obstructed. She arrived frightened.

Options: repeat somewhere else, or laparoscopy so that if something is there it can be fixed at the same time. She chose laparoscopy. Tubes were fine. It was user spasm (uterine spasm with dye) looking like blockage. What was not fine: horrendous endometriosis, deep infiltrating nodular disease, pulling structures. Excision by feel — you can pick the surface and miss the nodule underneath if you are not meticulous.

Six months later she was pregnant, and she has had her baby. Completely asymptomatic. Deep disease anyway. Excision of mild to moderate disease improves IVF success — and in this case it also preceded a spontaneous pregnancy.

Closing offer as spoken: if you have questions, call the rooms. The staff know to get things in front of the desk.

Take-home messages for clinic

1. Discuss AMH with reproductive-age women opportunistically, from about 25 — earlier if you already know they have significant endometriosis. If you will not order it, send them. The conversation is the point.
2. AMH under 10: refer regardless of age. Combined pill can falsely lower it — off for three months and repeat if they want the real number. Mirena does not. High AMH is reserve, not quality.
3. Low AMH does not lower the chance each cycle. It lowers how many cycles are left. Young plus low reserve plus good eggs is a different conversation from older plus low reserve.
4. Dedicated gynae imaging. QFW at Tugan: female sonographers, subspecialty obstetrician reports, HyCoSy and a separate endometriosis item number. Repeat a worrying generalist scan there before you operate on it. Warn that HyCoSy hurts. Spasm can look blocked.
5. Symptoms: never too early to investigate. Continuous combined pill if they will take it; trial and error; she is using more 30-microgram / Yasmin-type pills in young women because of bone-density data on very low oestrogen.
6. One in six couples need help. Refer early over 35, with endometriosis, AUB, distress, or male red flags. If you say keep trying under 35, check AMH, thyroid, prolactin, hormones, HbA1c, karyotype both, semen first.
7. Tubes before IUI. IVF cares less about tubes, still cares about polyps. “Complete excision” on a patient’s story may not have been complete. Silent deep endometriosis is a real entity. Excision of mild to moderate disease improves IVF success.
8. Vasectomy reversal is not a fertility plan until there is sperm. Check semen. After a long-standing vasectomy, TESA plus ICSI may be the honest option. Same-day pickup, both under anaesthetic.
9. Cancer and chemo: ring QFG. They can usually get a preservation cycle in. Do not assume the hospital already had the conversation.
10. Carrier screening: one rebate. The three-gene free test is not the best test. If they are heading into fertility care, the expanded panel is the rebate worth spending.

Dr Kotha · Gold Coast · reproductive-health.drkotha.com