[19] Management of Infertility Flashcards
What is the first step to managing a couple with infertility?
Support and reassurance
Why is support important in infertility?
Can be a very difficult time with external pressure and internal emotions
Do most cases of infertility require intervention?
No
Why is continuous reassurance important in infertility?
Couples often conceive whilst being investigated and stress can impact relationship
What external support may be helpful for couples with infertility?
- Support groups
- Counselling
What general advice can be given to couples with fertility problems?
- Folic acid
- Frequency of sexual intercourse
- Alcohol
- Smoking
- Weight
What information should women with fertility issues be told regarding folic acid?
They should take 0.4mg/day before conception and up to 12 weeks gestation
Why is folic acid supplementation advised?
To reduce the risk of neural tube defects
What frequency of sexual intercourse optimises chances of conception?
Every 2-3 days
How can alcohol affect fertility in men?
Can affect semen quality
How can alcohol affect fertility in woman?
Advised not to when trying to conceive as can harm any developing foetus
How can smoking affect fertility in men?
Can affect semen quality
What advice are women given about smoking when trying to conceive?
Smoking can harm any developing foetus
What advice are women given about their weight when trying to conceive?
Being BMI >30 or <19 may cause conception to take longer
How can a mans weight affect fertility?
Being over weight can reduce fertility
How are couples with infertility less than 18 months counselled?
By reassurance and lifestyle changes using a ‘wait and see policy’
When is a ‘wait and see’ policy for infertility not recommended?
After 18 months and for women over 30
Why is a wait and see policy not recommended for women over 30?
Waiting may have a significant adverse impact on her lifetime chance of conception using IVF
Where should women over 30 with infertility be referred to?
Rapidly to a specialist infertility clinic that has access to a full range of assisted reproductive technologies
What reproductive technologies can be offered by specialist clinics?
- IVF
- ICSI
- Intrauterine insemination
- Donor sperm and oocyte
How does management of ovulation disorders vary?
Depending on the group of ovulation disorder
What advice is given to women with Group I ovulation disorders to improve their chances of conception and uncomplicated pregnancy?
- Gain weight (if BMI <19)
- Moderate exercise (if undertaking high levels of exercise)
What treatment can be offered to women with Group I ovulation disorders?
Pulsatile administration of gonadotrophin releasing hormone or gonadotrophins with LH activity to induce ovulation
What treatment options are available for women with Group II ovulation disorders?
- Clomiphene citrate
- Laparoscopic Ovarian Diathermy
- FSH injections
When is clomiphene citrate the drug of choice for Group II ovulation disorders?
When there is stigmata of PCOS, normal FSH and prolactin levels
What % of subjects will clomiphene induce ovulation in?
80%
What proportion of women who ovulate on clomiphene will be able to conceive?
Half
How is clomiphene administered?
From day 2-6 of the cycle with an initial dose of 50mg/day increased to 100 and 150mg/day where necessary
How can ovulation be measured when using clomiphene?
Measuring day 21 progesterone levels
Why may using day 21 progesterone levels to measure ovulation on clomiphene be an issue?
Some women will become pregnant upon resuming ovulation
What are the reported rates of twin pregnancy in those who fall pregnant on clomiphene?
6-10%
What monitoring is recommended when using clomiphene?
USS monitoring of the follicles to identify two maturing follicles
What is recommended if two follicles are maturing when using clomiphene?
Abstention from sexual intercourse
What is the second line intervention for Group II ovulation disorders?
Laparoscopic ovarian diathermy
What % of PCOS patients does ovarian diathermy induce ovulation in?
70%
What is the advantage of laparoscopic ovarian diathermy to induce ovulation?
It carries no increased risk of multiple pregnancy and is a drug-free natural conception
What is an alternative second line intervention to laparoscopic ovarian diathermy?
FSH injections
What are the disadvantages of FSH injections to induce ovulation?
- Daily injection
- Can be costly
- USS and blood test monitoring is required
What are the risks of FSH injections?
- Over-response
- Multiple pregnancy
What treatment should women with Group II ovulation disorders be offered?
Dopamine agonists e.g. bromocriptine
How has the prevalence of tubal microsurgery changed as a method of managing infertility?
Decreased with the introduction of IVF
When is tubal microsurgery still used?
- Salpingectomy or tubal clipping prior to IVR in presence of hydrosalpynx
- Preliminary ovarian cystectomy or myomectomy
- Salpingolysis to release peritubal adhesions
- Salpingostomy - blocked tubal end held open
What risk increases following all forms of tubal surgery?
Risk of ectopic pregnancy
What is a myomectomy?
Operation to remove fibroids
What anaesthesia is used in a myomectomy?
GA
When can a myomectomy help to manage infertility?
When very large fibroids are making it difficult to become pregnant or fibroids must be removed for assisted conception
What are the risks of myomectomy?
- GA risk
- Bleeding
- Need for hysterectomy
- Damage to surrounding structures
Why may a hysterectomy be needed following a myomectomy?
When very heavy bleeding cannot be stopped and life is at risk
What are the potential complications of a myomectomy?
- Infection
- DVT and PE
- Pain
- Recurrence
What is assisted conception?
Procedures whereby treated or manipulated sperm are brought into proximity with oocytes
What are some examples of assisted conception?
- Intrauterine insemination (IUI) with partner or donor sperm
- IVF
- Intracytoplasmic sperm injection
What is IUI?
Introduction of prepared sperm into the uterine cavity around the time of ovulation
How does ovulation occur in preparation for IUI?
Can be stimulated with gonadotrophins or unstimulated
Who should unstimulated IUI be considered in?
- Unable to conceive vaginally due to disability or psychosexual problems
- Where consideration of method of conception is required e.g. male HIV
- People in same sex relationships
What is the physical requirement for IUI?
Healthy, patent fallopian tubes
What are the live birth rates for IUI in good quality centres?
15-20%
How does IUI compare to IVF in terms of cost effectiveness?
More cost effective
Why is IUI more cost effective than IVF?
- Lower doses of gonadotrophins
- Reduced monitoring
- Simplified laboratory requirements
What % of IVF treatments result in a live birth?
25%
What reduces the chance of IVF success?
Age of woman
How many cycles of IV should women under 40 be offered?
3
What should happen to IVF if a woman reaches 40 during treatment?
Current cycle should be completed then treatment withdrawn
How many cycles of IVF are offered to women over 40?
1 as long as they meet criteria
What criteria must women over 40 meet to be offered IVF?
- Never had past IVF
- No evidence of of low ovarian reserve
- Discussed implications of IVF and pregnancy at advanced age
How are eggs obtained in IVF?
Stimulation of multiple ovarian follicles using gonadotrophins and GnRH agonists/antagonists
Why are GnRH agonists/antagonists used in IVF?
To prevent premature LH surge and ovulation
How are oocytes collected for IVF?
Transvaginal ultrasound guided needle follicle aspiration with oocytes isolated from fluid
How are oocytes fertilised in IVF?
Cultured with a washed sample of sperm
How long are oocytes cultured for?
5 days to reach the blastocyst stage of division
Why are oocytes left to reach blastocyst form?
So a detailed assessment of morphological quality can be made
What is the most common obstetric problem associated with IVF?
Premature birth due to multiple pregnancy
How many embryos are transferred in IVF?
Recommendation is of one top-quality blastocyst when available
Why is transfer of one blastocyst recommended?
To reduce the risk of multiple pregnancy
What happens to the remaining blastocysts in IVF?
Cryopreserved for use later if conception fails
When may oocyte donation be appropriate?
- Premature ovarian failure
- Gonadal dysgenesis e.g. Turner syndrome
- Bilateral oophrectomy
- Ovarian failure following chemo or radiotherapy
- Some cases of IVF failure
- Where there is risk of transmitting genetic disorder
When is it unlikely therapy will help with male infertility?
- Small testes
- Azoospermia
- High FSH
- Low AMH
What is the most likely cause of male infertility if testes and FSH is normal?
Ductal obstruction
What test should be performed if ductal obstruction is the suspected cause of male infertility?
Testicular biopsy
What testicular biopsy result indicates likely ductal obstruction?
Normal spermatogenesis
What is the treatment for ductal obstruction causing male infertility?
Vasography and scrotal exploration followed by surgical anastamosis
What can help treat male infertility due to hypogonadotropic hypogonadism?
Gonadotrophins
What can be given to help improve fertility of men with hyperprolactinaemia?
Dopamine agonists
What are some unproven but widely practiced treatments for male infertility?
- Varicocele ligation
- Supplements
What is the most successful treatment for male infertility?
Intracytoplasmic Sperm Injection (ICSI)
What happens in ICSI?
A single immobilised sperm is injected into the oocyte cytoplasm
How do the pregnancy rates of ICSI compare to IVF?
Similar
What is the main concern with ICSI?
There is a slightly higher rate of abnormality in children conceived after ICSI
What are the main abnormalities seen in children following ICSI?
- Genital tract abnormalities e.g. hypospadias, testicular maldescent
- Imprinting disorders e.g. Angelman and Beckwith-Widemann syndromes
When is sperm donor insemination used?
If sperm cannot be obtained from the partner for ICSI or the partner is a carrier for a genetic disorder
What should be given to both parties of sperm donor insemination?
Independent counselling
Is sperm donation anonymous?
No
What has happened as a result of sperm donation being made non-anonymous?
Decrease in donation
How is sperm (and oocyte) donation not anonymous?
Children can meet their genetic parent under supervised conditions after 18 years of age
