14.Management and Treatment of the Infertile Couple Flashcards
What is the definition of Primary Infertility
The inability to conceive, despite regular unprotected sexual intercourse for 1 year
What is the definition of Secondary Infertility
The inability to conceive having had at least one pregnancy despite regular unprotected sexual intercourse for 1 year
What percentage of couples in any population, is infertile?
8-10%
What is the most common cause of infertility in women in sub-Saharan Africa?
Bilateral tubal occlusion
What is the most common cause of infertility in women in developed countries
No demonstrable cause
-Then ovulatory disorders
What percentage of infertile couples is caused by infertility in the female only in Sub-Saharan Africa
31%
What percentage of infertile couples is caused by infertility in the male only in Sub-Saharan Africa
22%
What percentage of infertile couples is caused by infertility in both partners in Sub-Saharan Africa
21%
What percentage of infertile couples is caused by infertility in the female only in developed countries
37%
What percentage of infertile couples is caused by infertility in the male only in developed countries
8%
What percentage of infertile couples is caused by infertility in both partners in developed countries
35%
What are the four steps in the clinical management of the infertile couple
History
Examination
Investigations
Treatment
What are five details taken when taking the history of the partners in an infertile couple
There is no substitute for a thorough history from both individuals
If they attend together, examine separately and ask about STI and undeclared pregnancies
Look for development of secondary sexual characteristics
Look for features of endocrine disorders
Examine the reproductive organs
When taking the he history of the ovarian cycle, list five aspects
Regular cycle?
Cervical mucous cascade
Moliminal(premenstrual) symptoms
Spasmodic dysmenorrhea
What is the examined when doing the Examination of the female half of the infertile couple
BMI Hair distribution Thyroid Breasts Vaginal/Pelvic Exam
In the examination for Hirsutism, which 11 sites are examined
Upper lip Chin Chest Upper back Lower back Upper abdomen Lower abdomen Forearm Arms Legs Thighs
What is the grade scale for Hirsutism
A scale from 1 to 4, 1 being a few hairs and four being heavy hair growth
What is the purpose of the Hirsutism scoring system
It allows initial assessment and facilities comparison whilst on treatment
List six social issues that can be contributing factors to infertility
Smoking Alcohol STI Obesity Occupation Exposure to heat Cell phones
To make a diagnosis at a PRIMARY care level, which 3 assessments/ tests are done
Test of ovulation
Tubal patency
Semen analysis
Which tests are performed at the SECONDARY and TERTIARY level when making a specific diagnose for infertility
Trans vaginal ultrasound Laparoscopy Hysteroscopy Endocrine anovulation work up Chromosomes
List 4 tests of Ovulation
Mid - Luteal (Day21) Progesterone level
Urinary LH
Serial T/V Ultrasound follicle scan
Basal body temperature
To diagnose Tubal Patency which tests are done
Hysterosalpingogram HSG
Laparoscopy and dye insufflation
List four male factors for infertility
Azoospermia
Oligozoospermia
Asthenozoospermia
Teratozoospermia
Define teratospermia/teratozoospermia
Defined as abnormal sperm morphology (shape)
Defined as abnormal sperm morphology (shape)
Teratozoospermia
Define asthenozoospemia
Reduced sperm motility
Reduced sperm motility
Asthenozoospermia
Define Oligozoospermia
Low sperm count
Low sperm count
Oligozoospermia
How is the Semenanalysis collected at the HWFMU
By appointment
Abstain for 2 days after compulsory ejaculation
Masturbation collection in a private secluded room
24 hour test
Diagnose the cause of infertility in this male: Volume 3.5mls Liquefaction: Complete Viscosity: Normal Sperm Count: 7M/ml Motility: 72% Progression 1.5
Oligospermic
Sperm Count is low (<20M/ml)
What are three surgical processes for sperm removal
PESA: Percutaneous Epididymal Sperm Aspiration
TESA: Testicular Sperm Aspiration
TESE: Testicular Sperm Extraction
List five steps in Counseling and Emotional Support for the infertile couple
Education on human fertility in general Their diagnosis in particular Treatment options Success rate Adoption
What advice would you give to the infertile male who drinks and smokes
Stop smoking
<3-4 units of alcohol/week
What is the treatment for erectile dysfunction
Viagra
Psychotherapy
What is the treatment for women who do not produce ova but which to become pregnant
Clomiphene
What are two types of Artificial Insemination
Artificial Insemination by Husband (AIH)
Artificial Insemination by Donor (DI)
What are three treatment methods for fertility with an infertile male
Artificial Insemination
Intrauterine Insemination
Assisted Conception
What are the treatment methods for the infertile female with amenorrhea
Treatment directed at the cause
E.G. Bromocriptine for hyperlactinaemia
What are the treatment methods for the infertile female with tubal occlusion
Surgery vs In Vitro Fertilization IVF
What are the treatment methods for the infertile female with Endometriosis
Medical and surgical treatment
What five treatments can be used for the Induction of ovulation
Clomiphene Citrate Letrozole hMG,human menopausal gonadotrophin Pure FSH GnRH agonists
What are the steps to induction of ovulation for Oligo-amenorrhea
Clomiphene citrate 50-100mg od po x 5days , from day 5-9 of the cycle
Serial ultrasound
- track follicle growth
Trigger ovulation with injection of hCG
What is the treatment for the female with ovarian failure
Oocyte donation
What is the treatment for the infertile female with hyperprolactinaemia
Dopamine agonist
Neurosurgical ablation
What is the treatment for the infertile female with Polycystic Ovarian Syndrome, PCOS
Metformin, clomiphene,ovarian endocoagulation
Describe the process of Intrauterine Insemination
Ovulation induction with ultrasound monitoring
Washed sperm instilled in the uterine cavity on the day of ovulation
Describe In Vitro Fertilization (IVF)
Fertilization in a glass dish
Define In vivo fertilizartion
Occurs in the fallopian tube
List 8 indications for In-Vitro Fertilization (IVF)
Tubal Factors Endometriosis Cervical factors Immunological causes Offspring of women treated with DES Male infertility Multifactorial infertility Unexplained infertility
List two examples of Tubal factors that are indications for in Vitro Fertilization
Irreversible tubal damage
Failed tubal surgery
List two examples of Endometriosis that are indications for in Vitro Fertilization
If no pregnancy after medical or surgical treatment
Oocyte recovery rate is lower with persistent stage III or IV organs
After resection ovarian function may be altered
List two examples of Cervical Factors that are indications for in Vitro Fertilization
Sperm fail to penetrate mucous
List two examples of immunological causes that are indications for in Vitro Fertilization
Anti-sperm antibodies
List two examples of male infertility that are indications for in Vitro Fertilization
Azoospermia amenable to treatment with intracytoplasmic sperm injection
What are five indications for Oocyte donation
Premature menopause Chemotherapy induced ovarian failure Autoimmune Ovarian Failure Physically inaccessible ovaries Autosomal dominant or sex linked disorders
What is the criteria for In Vitro Fertilization
Patients less than 40
(Over 40 have poor results with increased abortion rates)
Normal FSH
Ovulation spontaneous or readily induced
Good health (mental and physical)
In vitro fertilization IVF steps
Parenteral induction of ovulation
Oocyte retrieval
In vitro fertilization
Embryo transfer
How many embryos are implanted in the uterus in in vitro fertilization
3
What is the take home baby rate of in vitro fertilization
12-15%
List three other techniques for Artificial Pregnancy
Gamete Intra Fallopian Transfer
Zygote Intra Fallopian Transfer
PROnuclear Stage Oocyte Transfer
