23. Subfertility Flashcards
What is the definition of infertility?
Differentiate between primary and secondary infertility.
What is the current trend for infertility presentation?
What can infertility be due to?
Disease of the reproductive system defined by failure to acheive a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.
10: woman unable to ever bear a child, due to inability to become pregnant or to carry a pregnancy to a live birth. 20: same as 10 but following a previous pregnancy or ability to carry pregnancy to live birth.
Present earlier in their attempts at getting pregnant, but later in life.
Ovulatory disorders (25%), tubal damage (20%), uterine/peritoneal disorders (10%), male factors (30%). Both male and female can contribute to a case. Unexplained infertility (25%).
neurWhat are some things that should be included in general conception advice?
What are the 3 types (WHO classification) of ovulatory causes of infertility?
What is PCOS?
Intercourse throughout cycle, smoking, alcohol, folic acid, weight, stress, caffeine, drugs, occupation.
1) Hypopituitary failure (can be caused by anorexia). 2) Hypopituitary dysfunction e.g. PCOS, hyperprolactinaemia. 3) Ovarian failure (premature ovarian failure if under 40 yrs, confirmed by raised FSH).
1/3 of women in UK. Need 3 symptoms: clinical hyperandrogenamia + oligomenorrhoea + polycystic ovaries on ultrasound. BUT can have 1 or 2 so SPECTRUM of disease. Raised LH with normal FSH, raised testosterone. Associated metabolic abnormalites = risk of developing diabetes.
What are some tubal and uterine causes of infertility?
Describe PID.
PID, previous tubal surgery incl. tubal surgery for ectopic pregnancy, endometriosis (tubal and uterine), fibroids (uterine), cervical mucus defect.
Pelvic inflammatory disease: may be asymptomatic, >10% develop tubal infertility after 1 episode, 50% after 3. Acute: pelvic pain, deep dyspareunia, malaise, fever, purulent vaginal discharge. Examination: pyrexia, crevical excitation, adnexal tenderness. Treatment: antibiotics, rest, abstinence. May become chronic.
Describe endometriosis.
Describe fibroids.
Presence of tissue histologically similar to endometrium outside the uterine cavity and myometrium. Most commonly found in pelvis. 1/5 affected. COCP and pregnancy protect. Pain, dysmenorrhoea, menorrhagia, dyspareunia. Examination: pelvic tenderness/mass, fixed uterus. Treatment: NSAIDs for pain, norethisterone, GnRH antagonists, surgery.
Uterine leiomyoma (benign SM tumour of myometrium), about 20% of women. Heavy, regular periods. Often multiple, named by location. Physically obstruct pregnancy from occuring. Treatment: tran acid, COCP/LARCs, surgery.
What are some male causes of infertility?
List some drugs linked to infertility.
What are the NICE guidelines for referral to infertility services?
Testicular (infection, cancer, surgical, congenital, undescended testes, trauma), azoospermia +/- sperm Abs, vasectomy reversal, ejaculatory problems (retrograde and premature), hypogonadism.
Women: long-term NSAID, chemo, neuroleptics, spironolactone, depo-provera. Men: sulfasalazine, anabolic steroids, chemo, chinese herbs to improve sperm count. Both: marihuana, cocaine etc.
Woman aged 36 or over, and known clinical cuase of infertility/history of predisposing factors for infertility. But decision made by local CCG.
What investigations can a GP do prior to referral to infertility services?
What are some secondary care fertility investigations?
How is Type 1 ovulatory disorder (hypopituitary failure) treated?
Full sexual/contraception/fertility history. PCOS screen - day 21 progesterone, LH, FSH, serum testosterone, glucose. FBC (fibroids). TFTs/TSH. Vit D. HbA1c. Viral screen - rubella, HIV, hepatitis. STI screen, smear up to date. Semen analysis.
Ovulatory function: ovarian reserve testing. Tubal function: HSG, HyCoSy. Uterine function: laparoscopy.
Increase weight, decrease exercise, consider pulsatile GnRH or Gn with LH actvitiy to induce ovulation.
How is ovulatory disorder type 2 - PCOS treated?
How is ovulatory disorder type 2 - hyperprolactinaemia treated?
How is ovulatory disorder type 3 - ovarian failure treated?
How is tubal infertility managed?
Weight loss to BMI 30 or below. First line = clomiphene for 6/12 max or metformine (GI SEs). Second line = combined clomiphene and metformin, laproscopic ovarian drilling and Gn therapy.
Bromocriptine.
Donor eggs, alternative parenting strategies.
Laproscopic tubal surgery, surgery prior to IVF for fibroid clearance, adhesiolysis, endometrosis treatement.
How are male infertility factors managed?
How is unexplained fertility managed?
What is IUI?
Testicular: treat infections, surgery. Hypogonadism: consider gonadotropins.
DO NOT offer clomiphene - no increased chance of pregnancy/live birth. Continue sex for 2 years. Offer IVF after.
Intrauterine insemination. Sperm seperated in lab, remove slow sperm, inseminate partner. For those unable to have intercourse/wash sperm of HIV+ men/same-sex relationships. Fresh semen best. Insemination day 12-16 in woman not on ovarian stimulating drugs. Insemination via vaginal speclum and small catheter into womb. Success rates really drop >40 so not recommeded after 40.
What is IVF?
What is ovarian hyperstimulation syndrome?
Fertilisation of egg(s) outside body. Suppress cycle. Boost egg supply with gonadotropins. Monitor progress. Inject hormone to help eggs mature, collect eggs, mix with sperm and culture, transfer back into mum. Offer to women under 40 who haven’t conceived after 2 years. Can offer 1 cycle to 40-42yo if no evidece of low ovarian reserve, but more risks = diabetes, congenital problems. Success drops after 40.
Consequence of drugs used to stimulate ovarian function - gonadotropin or clomifene. Mild: lower abdo discomfort/distension +/- nausea. Severe: abdo pain/distension, ascites, pleural effusion, venous thrombosis. REFER.
What is ICSI?
What are some long-term safety issues related to assisted reproduction?
What are the options for people with cancer who wish to preserve fertility?
Intracytoplasmic sperm injection. Single sperm selected to be injected into egg. Used if severe deficits in semen quality, obstructive/non-obstructuve azoospermia, previous IVF failed. Consider genetic issues.
Ovarian induction and stimulation: no direct associations between treatments and cancer in mum/child. IVF: small increased risk of borderline ovarian tumours +/- ICSI. Absolute risk of long-term adverse outcomes for children low.
Cryopresevation of sperm/embryos/oocytes. Offer in adolescents undergoing chemo that will render them infertile.
