4. Infertility Flashcards
How many couples report infertility problems?
1 in 7
When are investigations taken to see if a couple are not compatible?
After 1 year of trying - unless there’s a problem:
- Period Irregularity
- Past Medical History
- Testicular Problems
- Abnormal Tests - HIV / HEP B
- Anxiety
- Age - < 35 years old
What are the general potential pathological problems, regarding Infertility?
- Are Eggs available?
- Are Sperm available?
- Can they meet?
What information is needed from a Female Reproductive History?
- Duration of Infertility
- Previous Contraception
- Fertility in Previous Relationships
- Previous Pregnancies and Complications
- Menstrual History
- Medical / Surgical History
- Sexual History
- Previous Investigations
- Psychological Assessment
What information is needed from a Female Reproductive Examination?
- Weight
- Height
- BMI (kg/m2)
- Fat and Hair Distribution (Hirsutism)
- Galactorrhoea
- Abdominal Examination
- Pelvic Examination
What is Hirsutism (and Acanthosis Nigricans) a sign of?
Androgen Excess:
- Testosterone
- Androstenedione
- Dehydroepiandrosterone (DHA)
- Dehydroepiandrosterone Sulphate (DHAS)
- 17-OH Progesterone
What is examined for in a Pelvic Examination?
- Masses
- Pelvic Distortion
- Fixed Retroversion
- Tenderness
- Fibroids - Pressure Symptoms / Period Problems / Infertility
What information is needed from a Male Reproductive History?
- Previous Infertility
- Medical / Surgical History
- Occupational History
- Sexual History
- Previous Investigations / Treatment
What information is needed from a Male Reproductive Examination?
- Weight
- Height
- BMI (Kg/m2)
- Fat and Hair Distribution (Hypoandrogenism)
- Abdominal / Inguinal Examination
- Genital Examination - Testes / Epididymis / Vas Deferens / Varicocoele / Penis
What can cause Epididymitis?
STD’s:
- Chlamydia Trachomatis
- Gonorrhoea
- NSTD
What is examined for int the Vas Deferens?
- Cystic Fibrosis Mutations
2. Congenital Bilateral Absence of the Vas Deferens
What is examined in the Genital Region?
- Testicle Size
- Testicular Maldescent:
- a) Orchidopexy
- b) Hypospadias
- c) Testicular Tumours
- Varicocele - abnormal dilation and Torsion of Veins
What are the Baseline Female Investigations?
- Rubella Immunity
- Chlamydia
- Thyroid Stimulating Hormone
- Mid-Luteal Progesterone (if irregular periods)
- Day 1-5 FSH, LH, PRL, TSH, Testosterone (if irregular periods)
What are the Baseline Male Investigations?
Male Semen Analysis - Computerised Semen Analysis
What investigations are undertaken at a Fertility Clinic?
- Pelvic Ultrasound
- Physical Examination
- Further Investigation
- Semen Analysis repeat
- Tubal Patency Test
What are 3 methods which can cause Eggs to not be available?
- Androgen Excess -
Clinical (Hirsutism) vs Biochemical (Testosterone) - Infrequent Periods (Anovulation)
- Polycystic Ovaries (Ultrasound)
What is the standard treatment for all Ovulatory Disorders?
- Treat the Underlying Cause
- Weight Loss / Gain for a BMI >18 and <35
- Ovulation Induction - Clomiefene / Gonadotrophins
How does Clomifene (Ovulation Iduction Medication) work?
It is a selective Oestrogen Receptor Modulator:
- It binds to Oestrogen Receptors in the Ovaries
- This causes the Hypothalamus to percieve a Hypoestrogenic State
- The Pituitary will then Release Gonadotrophins
What is the Dose Choice of Clomifene?
50mg - 150mg of day 2-6
Note - Progestogen Priming will need to be done in Amenorrhoea
How is Clomifene monitored?
Follicle scanning in the 1st Cycle
Note - 15% will require a dose adjustment
What are the side effects of Clomifene?
- Vasomotor
2. Visual
What is Gonadotrophin Medication (FSH Injection) used?
- No ovulation with Clomifene
- Ovulation but no pregnancy
Note - This is added to Clomifene
Note - there is up to 3-6 cycles of this
How can Endometriosis / Fibroids be treated?
- Surgically
2. Medically
If a patient has been sterilised and wants to get pregnant, what are the options?
- Reversal of Sterilisation - not available on the NHS
2. Consider In Vitro Fertilisation
What are the Treatment options if the problem is Sperm not being available?
- In Vitro Fertilisation (IVF) / Intracytoplasmic Sperm Injection (ICSI)
- Intra-uterine Insemination
- Surgery - Vasectomy reversal / Sperm retrieval
- Donor Insemination
What are the 2 categories, and associated types, of Azoospermia?
- Testicular:
- a) Hypo-Gonadotrophic
- b) Normo-Gonadotrophic
- c) Hyper-Gonadotrophic
- Post-Testicular:
- a) Iatrogenic
- b) Congenital
- c) Infective
What are the investigations for Azoospermia?
- History
- Examination
- Cystic Fibrosis Screen
- Hormone Levels:
- a) Follicular Stimulating Hormone
- b) Luteinizing Hormone
- c) Testosterone
- d) Karyotype
- e) Prolactin
What is the process of In Vetro Fertilisation (IVF)?
- Eggs Harvested from the Ovary
- Eggs Fertilised with Sperm in the Lab
- Embryo’s undergo a number of cell divisions
- Embryos are transferred to the Womb
What are the indications for In Vetro Fertilisation (IVF)?
Failure of:
- Tubual - Surgery
- Male - Donor / Intrauterine Insemination
- Ovulation - Clomifene / Gonadotrophins
- Unexplained - Superovulation / Intrauterine Insemination
What is Intracytoplasmic Sperm Injection?
Injection of Mature Eggs with a Single Sperm
