17 - Infertility Flashcards
Define infertility?
inability of a couple to conceive after 12 months of regular intercourse without use of contraception
How should the couple be seen at the consultation?
together -
because both partners are affected by decisions surrounding investigation and treatment
what is usually the % of couples who conceive within a year and which 2 factors play a role?
80% -
if woman is < 40yrs
no contraception and regular intercourse
of those who do not conceive in first year, what % conceive in their 2nd year of trying?
10%
What % of couples conceive within 2 years of trying?
90%
4 questions which must be asked to find the route of the infertility?
are eggs available?
are sperm available?
can egg and sperm meet?
can the embryo implant?
7 questions which both male and female partners should be asked as part of history?
Duration of infertility
Previous contraception
Fertility in previous relationships
Medical and surgical history
Sexual history
Previous investigations
Psychological assessment
2 questions women should be asked as part of their history?
Previous pregnancies and complications
Menstrual history
what should women be asked about their menstrual history? (3)
regularity
frequency
flow
7 things involved in female examination?
Weight
Height
BMI (kg/m2)
Fat and hair distribution
Galactorrhoea
Abdominal examination
Pelvic examination
define Galactorrhoea?
milk secretion from breasts not due to breast-feeding
what is hirsutism?
condition in women that results in excessive growth of dark or coarse hair in a male-like pattern — face, chest and back
reason for hirsutism?
NCCAH - non-classic congenital adrenal hyperplasia
why is diagnosis of PCOS important?
Polycystic Ovary Syndrome
Cushing’s syndrome
Acromegaly
what is the clinical measurement of Androgen excess?
Ferriman Gallwey Score
name 3 biochemical measurements of androgen excess?
testosterone
DHEAS >700 mcg/dL
17-OH progesterone
how does acanthosis nicrigans present and what does it indicate?
dark lines under the arms/ at the back of the neck
indicates androgen excess
5 possible findings on a pelvic examination?
masses
pelvic distortion
tenderness
vaginal septum
cervical abnormalities
3 ways in which fibroids can present?
pressure symptoms
period problems
infertility
3 baseline investigations for women?
Rubella immunity
Chlamydia
TSH
which other investigation should women undergo, depending on their periods?
regular periods - mid luteal progesterone
irregular - day 1-5 FSH, LH, PRL, TSH, testosterone
which baseline investigation should be done for men?
semen analysis
describe 5 investigations to be carried out at the fertility clinic?
Pelvic Ultrasound
Physical examination
Testing for ovulation
Semen analysis repeat if required
Tubal patency test
when should a tubal patency test be performed?
just after period has finished but before you ovulate -
~day 7 - 12 of regular 28 day menstrual cycle
what is tubal patency test used for?
ultrasound procedure used to assess the patency of the fallopian tubes and detect abnormalities of the uterus and endometrium
what should women with regular monthly menstrual cycles be told?
that they are likely to be ovulating
what should women be offered to confirm ovulation? (even if regular cycles)
blood test to measure serum progesterone
in mid-luteal phase
what should women with irregular cycles be offered to confirm ovulation?
blood test to measure serum progesterone (later in cycle) and LH and FSH
what should women with no comorbidities be offered to screen for tubal/ uterine abnormalities?
HSG - HysteroSalpingoGraphy
what is HSG a good test for?
good for ruling out tubal occlusion
what is tubal patency test AKA?
HyCoSy
what 3 things should men be asked in terms of developmental history?
testicular descent
change in shaving frequency
loss of body hair
which 2 infections should men be specifically asked about?
mumps
STDs
which 2 surgical procedures should men be specifically asked about?
variocele repair
vasectomy
which 6 environmental/ drugs factors should men be asked about?
alcohol
smoking
anabolic steroids (bodybuilding)
chemotherapy
radiation
recreational drugs
which 3 questions should men be asked about in terms of sexual history?
libido (sex drive)
frequency of intercourse
previous fertility assessment
what 6 things are involved in male examination?
Weight
Height
BMI (kg/m2)
Fat and hair distribution (hypoandrogenism)
Abdominal and inguinal examination
Genital examination
what 4 things are assessed in a male genital examination?
Epididymis
Testes
Vas deferens
Varicocele
what does epididymitis cause?
seminiferous tubular necrosis and disrupts spermatogenesis
name 4 causes of epididymitis?
Chlamydia trachomatis
Gonorrhoea
TB
Mumps
what is a varicocele?
dilatation of the pampiniform plexus of the spermatic veins in the scrotum
why are varicoceles more common on the left side?
due to anatomical venous drainage
where does the internal spermatic vein drain into on the RIGHT side?
inferior vena cava
where does the internal spermatic vein drain into on the LEFT side?
left renal vein @ a right angle
describe 2 treatment methods for varicocele which are NOT recommended?
surgery
embolisation
what is Klinefelter syndrome?
one of most common causes of hypogonadism with impaired spermatogenesis
how is Klinefelter’s characterised?
aneuploidy - an extra X (XXY) chromosome being the most frequent
how does Klinefelter’s present in patients?
very small testes
azoospermia (almost always)
define azoospermia?
semen contains no sperm
name 2 conditions affecting vas deferens?
Cystic fibrosis
CBAVD (congenital bilateral absence of vas deferens)
how many groups of ovulatory disorders are there?
3
describe group I of ovulatory disorders?
hypothalamic pituitary failure
describe group II of ovulatory disorders?
hypothalamic-pituitary-ovarian dysfunction
describe group III of ovulatory disorders?
ovarian failure
Group I ovulatory disorders - treatment and management?
increase body weight if BMI < 19 / reduce exercise if it is excessive
gonadotrophin-releasing hormone/ clomifene
(to induce ovulation)
4 ways to diagnose PCOS?
androgen excess - Hirsutism, Testosterone
infrequent periods - anovulation
polycystic ovaries - US scan
what type of drug is Clomifene?
selective oestrogen receptor modulator
recommended does for clomifene?
50mg – 150mg Day 2-6
2 ways in which to manage clomifene?
Follicle scanning in 1st cycle
15% require dose adjustment
2 side effects of clomifene?
vasomotor
visual
what should women with hydrosalpinges be offered as a treatment?
salpingectomy by laparoscopy before IVF treatment
2 surgical sperm retrieval procedures for azoospermia?
Micro-epididymal sperm aspiration
Testicular sperm extraction
what should women with unexplained infertility be offered rather than Clomifene?
IVF treatment
why can women with unexplained fertility NOT be given clomifene?
it is a stand-alone treatment and does not increase the chances of a pregnancy or a live birth
describe the process of ICSI - intracytoplasmic sperm injection?
injection of MATURE eggs with single sperm before incubating overnight
