5: Management of infertility Flashcards
What is the definition of infertility?
Failure to become pregnant despite 12+ months of unprotected sexual intercourse (without a known reason)
What is
a) primary
b) secondary infertility?
a) Primary - couple has never conceived
b) Secondary - couple has conceived before (but stillborn or ectopic)
The incidence of infertility is (increasing / decreasing).
increasing
What percentage of couples experience infertility?
15%
A BMI over ___ increases your likelihood of infertility.
over 30
As a woman, the older you are, the (more / less) fertile you are.
After puberty, older = less fertile
Under female causes of infertility, what are the two broad categories of disease?
Tubal disorders
Ovulatory disorders
Where in the Fallopian tubes does fertilisation occur?
Ampulla
Where do fertilised eggs implant?
Uterine wall
Which STI causes infertility?
Chlamydia
When in the luteal phase are progesterone levels usually checked?
Mid-phase
i.e a week after ovulation / a week before menstruation
as this is when progesterone levels should peak
A progesterone level of more than ___ nmol/L suggests that ovulation has occurred.
30 nmol/L
Which hormones should be checked in a woman who has oligo- or amenorrhoea?
GnRH
FSH and LH
Oestradiol, testosterone
Prolactin
TSH (for thyroid problems)
Which virus causes either miscarriage or severe congenital disease in babies whose mothers are infected?
Rubella virus
What disease does the Rubella virus cause in unborn babies?
Congenital rubella syndrome
What are the characteristic signs of congenital Rubella syndrome?
Rash
Microcephaly (smaller head circumference than normal)
Patent ductus arteriosus
Cataracts
How is congenital Rubella syndrome prevented?
MMR vaccine
measles, mumps, rubella
What is a bacterium which commonly causes pelvic inflammatory disease, leading to female infertility?
Chlamydia trachomatis
Chlamydia trachomatis is a Gram (positive / negative) coccobacillus.
Gram negative
What are two reproductive consequences of Chlamydia infection?
Infertility
Ectopic pregnancy
Which antibiotics are used to treat Chlamydia infection?
Azithromycin
OR
Doxycycline
What is a possible acute consequence of pelvic inflammatory disease?
Peritonitis
What type of menstrual cycle indicates that ovulation is occurring normally?
Regular cycles
What types of menstrual cycle indicate that ovulation isn’t occurring?
Prolonged cycles (oligomenorrhoea, >35 days)
No period (amenorrhoea)
Ovulation, indicated by regular cycles, is confirmed by which test?
Midluteal progesterone test
Anovulation, indicated by irregular/no cycles, is confirmed by which tests?
Hormone tests
(GnRH, gonadotrophins, oestradiol, testosterone, PRL, TSH)
Why is TSH tested in women with anovulation?
Hyper/hypothyroidism both cause ovulatory disorders
What are the three broad causes of ovulatory disorders?
I: hypothalamic - stress, anorexia, exercise, Kallmann syndrome
II: pituitary - PCOS, hyperprolactinaemia
III: ovarian failure - menopause, premature
What is the first line treatment for PCOS?
Clomifene citrate
How does clomifene citrate work?
SERM
Selective oestrogen receptor modulator
Blocks oestrogen receptors in the ovaries, leading to perceived low oestrogen levels, leading to increased secretion of GnRH > FSH & LH by negative feedback, causing more follicles to develop
… increasing your chances of pregnancy
Clomifene citrate causes what?
Ovulation induction
Does ovulation induction increase your chance of conceiving?
Yes, but not by 100%
What is a reproductive “risk” of clomifene citrate?
Increased chance of multiple pregnancy i.e twins, triplets
What is an alternative to clomifene citrate which also produces ovulation induction?
Tamoxifen
If ovulation induction via clomifene citrate or similar doesn’t work, what are second line options for women with PCOS?
Gonadotrophin injections
Laparoscopic ovarian diathermy (drilling)
What is the first line investigation for male infertility?
Semen analysis
If semen analysis is abnormal, what is the second line investigation for male infertility?
Hormone tests
GnRH, FSH and LH, testosterone, prolactin, TSH
Male sperm counts are (increasing / decreasing).
decreasing
which is bad
What are some obstructive causes of male infertility?
Vasectomy
STI (chlamydia, gonorrhoea)
Congenital absence of vas deferens in CF
What are some non-obstructive causes of male infertility?
Undescended testes
Orchitis (testicular inflammation caused by chlamydia, gonorrhoea or mumps)
Testicular trauma
Klinefelter’s syndrome (47 XXY)
Which syndrome, also known as primary ciliary dyskinesia, can cause non-obstructive male infertility?
Kartagener’s syndrome
What are some hormonal causes of male infertility?
Hypogonadotrophic hypogonadism
Hyperprolactinaemia
Hypothyroidism
What is a condition associated with diabetes which may result in male infertility?
Erectile dysfunction
How is male infertility treated or worked around?
Surgery to remove vas deferens obstruction
Artificial insemination
What investigation can be used to check tubal patency in females?
Hysterosalpingogram
Which imaging test is used to check for pelvic inflammatory disease in females?
Laparoscopy
Which disease, characterised by ectopic endometrial tissue, is a cause of female infertility?
Endometriosis
How is tubal disease treated?
Surgery
If tubal disease cannot be treated, what method of fertilisation is used to achieve a pregnancy?
IVF
In vitro fertilisation
How does IVF work?
Unfertilised egg extracted from female
Egg fertilised in lab using partner/donor sperm
Fertilised egg artificially implanted back in female’s uterus
How often should couples aiming to conceive have sex?
2-3 times a week
What lifestyle factors should be considered when managing infertility?
Alcohol
Weight
Smoking
What supplement should all pregnant women be on?
Folic acid
What virus should all pregnant women be immunised against?
Rubella
Pregnant women should receive which kind of smear test?
Cervical smear
for cervical cancer
Which genetic condition causes premature ovarian failure?
Turner’s syndrome 45 XO
How may women with premature ovarian failure achieve pregnancy?
Egg donation
Which bone disease may women with premature ovarian failure develop?
Osteoporosis
so put them on combined oral contraceptive pill
What are the common investigations done for couples experiencing infertility?
For the woman:
Pregnancy test (just in case), all hormones, progesterone test (for ovulatory disorders), Rubella and Chlamydia
For the man:
Semen analysis, tubal patency test
