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Reproductive Health (Y4) > 5- Infertility > Flashcards

5- Infertility Flashcards

1
Q

Subfertility

A

a couple who are having regular (every 2-3 days), unprotected sex who have failed to conceive within 1 year

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2
Q

Primary infertility

A

never been pregnancy

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3
Q

Secondary infertility

A

previous pregnancy
- Ectopic and termination included

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4
Q

how many couples will struggle to conceive naturally

§

A

1 in 7

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5
Q

when should investigation into infertility start

A

After the couple has been trying to conceive without success for 12 months.
- This can be reduced to 6 months if the woman is older than 35, as her ovarian stores are likely to be already reduced and time is more precious.

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6
Q

causes of infertility

A

Causes

  • Sperm problems (30%)
  • Ovulation problems (25%)
  • Tubal problems (15%)
  • Uterine problems (10%)
  • Unexplained (20%)
    40% of infertile couples have a mix of male and female causes.
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7
Q

causes of female infertility can be related to

A
  • ovulatory causes
  • uterine and peritoneal disorders
  • tubal damage
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8
Q

ovulatory causes of infertility

A

Causes of anovulation:

Group I- hypothalamic pituitary failure- 10%

  • Hypothalamic amenorrhoea
  • Hypogonadotropic hypogonadism

Group II- hypothalamic-pituitary-ovarian dysfunction- 85%

  • PCOS
  • Hyperprolactinaemic amenorrhoea

Group III- Ovarian failure- 5%

  • Premature ovarian failure
  • Congenital e.g. Turners syndrome (45xO)
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9
Q

Uterine and peritoneal disorders

A

Conditions causing scarring/ adhesions
- Endometriosis
- PID
- Previous surgery
- Asherman syndrome- scaring within uterus e.g. after procedure

Mullerian developmental abnormalities

Uterine fibroids

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10
Q

tubal damage

A

Conditions affecting fallopian tube- disrupted transport of ovum e.g.
- Endometriosis
- Ectopic pregnancy
- Pelvic surgery
- PID
- Mullerian developmental anomaly- agenesis

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11
Q

General Advice for pregnancy

A
  • The woman should be taking 400mcg folic acid daily
  • Aim for a healthy BMI
  • Avoid smoking and drinking excessive alcohol
  • Reduce stress as this may negatively affect libido and the relationship
  • Aim for intercourse every 2 – 3 days
  • Avoid timing intercourse
    *
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12
Q

how many mcg of folic acid daily

A

400 mcg

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13
Q

timed intercourse

A

to coincide with ovulation is not necessary or recommended as it can lead to increased stress and pressure in the relationship.

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14
Q

female infertility history

A

Not essential in the absence of any relevant history
Scrotum – varicocele
Testicular size
Testicular position – undescended testes
Prostate – chronic infection

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15
Q

female infertility examination

A
  • BMI
  • Secondary sexual characteristics e.g. Body hair distribution
  • Galactorrhoea
  • Abdominal/Pelvic/ vaginal – structural abnormalities e.g. fixed or tender uterus
  • hirsutism/ acne
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16
Q

investigations for infertility

A
  • BMI
  • chlamydia screening
  • rubella immunity in the mother
  • semen analysis
  • female hormonal testing
  • tests of tubal patency
  • US pelvis
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17
Q

female hormone testing involves which hormones

A
  • Serum LH and FSH on day 2 to 5 of the cycle
  • Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle).
  • Anti-Mullerian hormone
  • Thyroid function tests when symptoms are suggestive
  • Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea
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18
Q

what does high FSH suggest

A

poor ovarian reserve (the number of follicles that the woman has left in her ovaries).

The pituitary gland is producing extra FSH in an attempt to stimulate follicular development.

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19
Q

high LH may be suggestive of

A

PCOS

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20
Q

what does a rise in progesterone on day 21 indicate

A

normal
indicates that ovulation has occurred, and the corpus luteum has formed and started secreting progesterone.

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21
Q

when is anti-mullerian hormone measured

A

any time during the cycle

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22
Q

anti-mullerian hormone is the most accurate marker of

A

ovarian reserve
- released by granulosa cells in the follicles
- falls as eggs are depleted

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23
Q

high anti- mullerian hormone indicates

A

good ovarian reserve

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24
Q

Low BMI

A

could indicate anovulation

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25
Q

high BMI could indicate

A

PCOS

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26
Q

Ultrasound pelvis

A

to look for polycystic ovaries or any structural abnormalities in the uterus

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27
Q

what is a hystersterosalpingogram used to look at

A

patency of the fallopian tubes

28
Q

hystersterosalpingogram

A

can be both diagnostic and therapeutic

How is works: small tube is inserted into the cervix. A contrast medium is injected through the tube and fills the uterine cavity and fallopian tubes. Xray images are taken, and the contrast shows up on the xray giving an outline of the uterus and tubes. If the dye does not fill one of the tubes, this will be seen on an xray and suggests a tubal obstruction.

Diagnostic
- **scan used to assess shape of uterus and patency of fallopian tubes
**
Theraputic
- procedure seems to increase rate oc conception
- tubal cannulation under xray guidance can be performed to oepn up the tubes **

29
Q

risk of hysterosalpingogram

A

infection (abx given prophylactically) - screening for chlamydia and gonorrhoea should be done before the procedure

30
Q

Laparoscopy and Dye Test

A

The patient is admitted for laparoscopy. During the procedure, dye is injected into the uterus and should be seen entering the fallopian tubes and spilling out at the ends of the tubes. This will not be seen when there is tubal obstruction. During laparoscopy, the surgeon can also assess for endometriosis or pelvic adhesions and treat these.

31
Q

management of infertility caused by anovulation

A
  • Weight loss for overweight patients with PCOS can restore ovulation
  • Clomifene may be used to stimulate ovulation
  • Letrozole may be used instead of clomifene to stimulate ovulation (aromatase inhibitor with anti-oestrogen effects)
  • Gonadotropins may be used to stimulate ovulation in women resistant to clomifene
  • Ovarian drilling may be used in polycystic ovarian syndrome
  • Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)
32
Q

management of infertility caused by PCOS

A
  • weight loss
  • ovarian drilling
  • metformin (if insulin insensitivity and obesity)
33
Q

which agents can be used to stimulate ovulation

A

1) first line: Clomifene
2) second line : Letrozole (aromatase inhibitor with anti-oestrogen effects)
3) third line: Honadodrophins

34
Q

clomifene MOA

A

anti-oestrogen (a selective oestrogen receptor modulator).
- stops negative feedback of oestrogen on the hypothalamus
- causes more GnRH and subsequently more FSH and LH
- therefore higher chance of ovulation

35
Q

clomifene MOA

A

anti-oestrogen (a selective oestrogen receptor modulator).
- stops negative feedback of oestrogen on the hypothalamus
- causes more GnRH and subsequently more FSH and LH
- therefore higher chance of ovulation

36
Q

how is clomifene given

A

given on days 2 to 6 of the menstrual cycle.

37
Q

side effects of clomifene

A

flushing (feeling of warmth)
upset stomach.
vomiting.
breast discomfort.
headache.
abnormal vaginal bleedin

38
Q

side effects of letrozole

A

hot flushes.
night sweats.
nausea.
vomiting.
loss of appetite.
constipation.
diarrhea.
heartburn.

39
Q

Ovarian drilling

A

involves laparoscopic surgery. The surgeon punctures multiple holes in the ovaries using diathermy or laser therapy. This can improve the woman’s hormonal profile and result in regular ovulation and fertility.

40
Q

which agents are used to treat anovulation caused by hyperprolactinoma

A

Dopamine agonists (Hyperprolactinaemia)

41
Q

Management of Tubal Factors

A
  • Tubal cannulation during a hysterosalpingogram
  • Laparoscopy to remove adhesions or endometriosis
  • In vitro fertilisation (IVF)
42
Q

Management of Uterine Factors

A

Surgery may be used to correct polyps, adhesions or structural abnormalities affecting fertility.

43
Q

male infertility history

A

General health
Alcohol/smoking
Previous surgery
Previous infections
Sexual dysfunction – erectile/ ejaculatory

44
Q

male infertility examination

A
  • Not essential in the absence of any relevant history
  • Scrotum – varicocele
  • Testicular size
  • Testicular position – undescended testes
  • Prostate – chronic infection
  • secondary sexual characteristics
45
Q

Investigations for men

A

x2 semen samples

46
Q

summary of infertility history taking

A
47
Q

male causes of ifnertility summary

A
  • pre-testicular
  • testicular
  • post-testicular
48
Q

Referral to secondary care

A
  • Differs locally
  • Consider referral if Hx, exam and Ix normal in both partners and not conceived after a year
  • Consider early referral in
    o Women >36 (after 6 months)
    o Known cause/ predisposing factors
  • Offer counselling throughout process
49
Q

management options sumamry

A
  • Medical treatment- ovulation induction e.g. Clomifene
  • Surgical treatment – to rx tubal occlusion e.g. laparoscopy
  • Assisted reproductive technology (ART) = means of conception other than normal coitus e.g. intrauterine insemination, IVF etc
50
Q

what is semen analysis

A

used to examine the quantity and quality of semen and sperm.
It assesses for male factor infertility.

51
Q

providing a semen sample

A
  • Abstain from ejaculation for at least 3 days and at most 7 days
  • Avoid hot baths, sauna and tight underwear during the lead up to providing a sample
  • Attempt to catch the full sample
  • Deliver the sample to the lab within 1 hour of ejaculation
  • Keep the sample warm (e.g. in underwear) before delivery
52
Q

Factors Affecting Semen Analysis and Sperm Quality and Quantity

A

Hot baths
Tight underwear
Smoking
Alcohol
Raised BMI
Caffeine

A repeat sample is indicated after 3 months in borderline results or earlier (2 – 4 weeks) with very abnormal results.

53
Q

normal semen results

A
  • Semen volume (more than 1.5ml)
  • Semen pH (greater than 7.2)
  • Concentration of sperm (more than 15 million per ml)
  • Total number of sperm (more than 39 million per sample)
  • Motility of sperm (more than 40% of sperm are mobile)
  • Vitality of sperm (more than 58% of sperm are active)
  • Percentage of normal sperm (more than 4%)
54
Q

define polyspermia

A

refers to a high number of sperm in the semen sample (more than 250 million per ml).

55
Q

define normospermia

A

refers to normal characteristics of the sperm in the semen sample.

56
Q

oligospermia

A

is a reduced number of sperm in the semen sample. It is classified as:

  • Mild oligospermia (10 to 15 million / ml)
  • Moderate oligospermia (5 to 10 million / ml)
  • Severe oligospermia (less than 5 million / ml)
57
Q

Cryptozoospermia

A

refers to very few sperm in the semen sample (less than 1 million / ml).

58
Q

Azoospermia is the absence of sperm in the semen.

A

Azoospermia is the absence of sperm in the semen.

59
Q

Pre-Testicular Causes

A

Testosterone is necessary for sperm creation. The hypothalamo-pituitary-gonadal axis controls testosterone.

Hypogonadotrophic hypogonadism (low LH and FSH resulting in low testosterone), can be due to:

1) Pathology of the pituitary gland or hypothalamus
2) Suppression due to stress, chronic conditions or hyperprolactinaemia
3) Kallman syndrome

60
Q

kallmans syndrome

A

a genetic disorder that prevents a person from starting or fully completing puberty- a form of a group of conditions termed hypogonadotropic hypogonadism.

To distinguish it from other forms of hypogonadotropic hypogonadism, Kallmann syndrome has the additional symptom of a total lack of sense of smell (anosmia) or a reduced sense of smell.

If left untreated, people will have poorly defined secondary sexual characteristics, show signs of hypogonadism, almost invariably are infertile and are at increased risk of developing osteoporosis.

61
Q

Testicular Causes

A

Testicular damage from:
*
* Mumps
* Undescended testes
* Trauma
* Radiotherapy
* Chemotherapy
* Cancer

Genetic or congenital disorders that result in defective or absent sperm production, such as:

  • Klinefelter syndrome
  • Y chromosome deletions
  • Sertoli cell-only syndrome
  • Anorchia (absent testes)
    *
62
Q

klinefelter syndrome

A

XXY, is a syndrome where a male has an additional copy of the X chromosome.

The primary features are infertility and small, poorly functioning testicles

63
Q

Post-Testicular Causes

A

Obstruction preventing sperm being ejaculated can be caused by:

  • Damage to the testicle or vas deferens from trauma, surgery or cancer
  • Ejaculatory duct obstruction
  • Retrograde ejaculation
  • Scarring from epididymitis, for example, caused by chlamydia
  • Absence of the vas deferens (may be associated with cystic fibrosis)
  • Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)
64
Q

patients with abnormal semen analysis

A

referred to urologists

  • Hormonal analysis with LH, FSH and testosterone levels
  • Genetic testing
  • Further imaging, such as transrectal ultrasound or MRI
  • Vasography, which involves injecting contrast into the vas deferens and performing xray to assess for obstruction
  • Testicular biopsy
    *
65
Q

management of male infertilty

A
  • Surgical sperm retrieval where there is obstruction
  • Surgical correction of an obstruction in the vas deferens
  • Intra-uterine insemination involves separating high-quality sperm, then injecting them into the uterus
  • Intracytoplasmic sperm injection (ICSI) involves injecting sperm directly into the cytoplasm of an egg
  • Donor insemination involves sperm from a donor

Reproductive Health (Y4) (34 decks)

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