3. challenges to female fertility Flashcards
Infertility in AUS stats
- Infertility affects 1 in 7 couples and many need ART (assisted reproductive technology) to conceive
- Three common methods are:
○ Invitro fertilisation (IVF). ICSI (one sperm injected into one egg
○ Intrauterine insemination (IUI) takes the sperm and put it into the womb
○ Ovulation induction: timed intercourse after induced ovulation - 8 million children born from ART
Cryopreservation (egg, sperm, embryo and tissue freezing to preserve fertility)
Polycystic ovarian syndrome PCOS
- An endocrine disorder that has gynaecological implications
- A cluster of symptoms (the rotter dam criteria 2/3 of these symptoms)
○ Hyperandrogenism: high levels of androgens e.g, facial and back acne, increased hair growth, blood test
○ Oglioanovulation: don’t ovulate every month
○ PCOM: PCO morphology via ultrasound can spot cysts, these cysts are follicles/ eggs - To diagnose must rule out: CAH, Cushings syndrome, adrenal tumours, thyroid disorders, FHA
how does PCOS develop
- Genetics
- Insulin resistance
- How to ovaries respond to hormones
- Lifestyle
- refer to notes table
PCOS management
Weight loss
- 5-10kg weight loss (5-10%) leads to;
- Reduced insulin resistance by 50%
- Restore ovulation and regulate cycles
- Improve fertility and reduce pregnancy complications
- Improve the health of the child in pregnancy and beyond Improve emotional health
- Reduce the chance of diabetes and heart disease
PCOS’s long term effects
reproductive outcomes
non reproductive outcomes
Reproductive health issues
- Endometrial glandular hyperplasia
- Menstrual problems – 19 x increased risk
- Hysteroscopy D+C, ablation, hysterectomy
- Infertility – 11 x increased risk
- Spontaneous MC/ectopic IVF/assisted reproduction
Non reproductive health
- Endocrine – late onset T2DM – 4x increased risk
- Circulatory – HT, CVD, IHD, thrombotic risk – 2 x increased risk
- Respiratory – asthma
- Mental – depression, anxiety, self harm, drug use
- Cancer – endometrial – 22 x increased risk breast, skin
- External causes - adverse medical treatment, self harm, accidents
Endometriosis
- Inflammatory disease associated with pelvic pain and infertility that is characterized by lesions of endometrial-like tissue outside of the uterus
- 5-10% reproductive age
- 176 million women worldwide
- Main presenting features
○ Pain
○ Infertility
○ Both
Endometriosis
- Inflammatory disease associated with pelvic pain and infertility that is characterized by lesions of endometrial-like tissue outside of the uterus
- 5-10% reproductive age
- 176 million women worldwide
- Main presenting features
○ Pain
○ Infertility
○ Both
What causes endo
- Immune: failure of immune mechanisms to destroy ectopic tissue + abnormal differentiation of endometriotic tissue
- Stromal cell defect associated with increased estrogen and prostaglandins
- Resistance to progesterone
- Pathogenesis
○ Retrograde Menstruation (Sampson)
○ Coelomic Metaplasia
○ Circulation/Implantation of ectopic tissue via venous/lymphatic system
○ Genetic/epigenetic - A complex mix of these factors, there is still much research to be done
How does endo affect fertility
- Abnormal follicular environment - very inflamed
- Distorted anatomy - adhesions in the pelvis might block the tubes
- Impaired cilial function
- Embryotoxic - toxic for embryo
- Abnormal eutopic endometrium - embryo doesn’t stick
Diagnosis of endo,
signs and symptoms and prevalence
Symptoms
- Dysmenorrhea – 62%
- Chronic pain – 57%
- Deep dyspareunia – 55%
- Cyclical interstitial complaints
- Fatigue/weariness Infertility – 40%
Signs
- Abdominal masses
- Pelvic signs
○ POD nodularity
○ Immobility of organs
○ Tenderness
○ Masses
Visible endometriotic nodules
Non-invasive investigations to diagnose Endo
Gupta et al 2016 Cochrane Review on Biomarkers for Endometriosis
Triage tests – rule disease out Imaging – none Urinary/blood/endometrial – none Combined – pelvic exam + TVUS – for DIE – effective
Triage tests – rule disease in Imaging – TVUS/MRI for DIE or endometrioma Urinary/blood/endometrial – none Combine – pelvic exam + TVUS - for mapping DIE
Laparoscopic diagnosis is the gold standard and is minimally invasive but still not perfect (Sn 94%, Sp 79%)
Endometriosis pain surgery
- Laparoscopic – diagnosis and treatment Excisional = ablative - not well studied (cutting away tissue)
- Hormonal suppression beyond surgery – secondary prevention not reduction of pain LNG-IUD ?
Role for nutritional or complementary medicines
Surgery for infertility caused by endo
- Hormonal therapies – ineffective in treatment for fertility
- Laparoscopy – diagnosis and treatment
- Excisional > ablative - not well studied
- Endometrioma >3cm – cystectomy
- Adjunctive GnRHa prior to surgery for DIE - controversial
- Hormonal suppression beyond surgery Spontaneous cumulative pregnancy rates following surgery 46-77% - stage I/II disease Spontaneous pregnancy rates lesser in Stage III/IV disease – limited data
