6.1 Infertility Flashcards
When do you refer a couple for infertility?
After 12months of trying
Or after 6 months if the woman is >35yrs as ovarian stores and time more precious
What % of couples conceive within a year of UPSI? How many struggle?
85%
1 in 7 will struggle
What are the main causes of infertility and the percentage prevalence of each?
Sperm/male 30%
Unexplained 25%
Female (45%)
- ovulation 25%
- tubal 20%
- other/ uterine/ peritoneal 10%
(yeah NICE percentages dont add up!)
40% of infertile couple have a mix of male and female factors.
Infertility due to ovulatory disorders (25%) can be classified into what 3 groups?
10% Group I: hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism).
85% Group II: hypothalamic pituitary dysfunction (predominantly PCOS).
4-5% Group III: ovarian failure
What are some causes of ovulatory Group 1 infertility disorders?
Group I: hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism).
● 10% of ovulatory disorders
● Anterior pituitary macro or microadenoma
● Hypothalamic causes - e.g. anorexia nervosa
● Sheehan’s syndrome
● Kallmann’s syndrome
● Thyroid
● Adrenal
● Chronic debilitating disease (e.g. uncontrolled diabetes, cancer, AIDS, end-stage kidney disease, and malabsorption
What is some general advice for couples trying to conceive?
- woman takes 400micrograms folic acid OD
- 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/timed intercourse (trying to coincide with ovulation)
Initial primary care Ix for infertility?
- BMI (low could indicate anovulation, high could indicate PCOS)
- Chlamydia screening
- Semen analysis
- Female hormonal testing
- Rubella immunity in the mother
What female hormones should be tested and when should they be tested when Ix infertility?
- LH and FSH on day 2 to 5 of the cycle
- 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 (ovarian reserve)
- TFTs when Sx are suggestive
- Prolactin (hyperprolactinaemia is a cause of anovulation) when Sx of galactorrhea or amenorrhoea
In “Group I: hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism)” ovulatory disorder what hormone changes would you expect to see?
Low FSH and low LH
In “Group II: hypothalamic pituitary dysfunction (predominantly PCOS)” ovulation disorder what hormone profile would you expect?
normal FSH and, normal or high LH
In “Group III: ovarian failure” ovulatory problem what hormone profile would you expect to see?
high FSH and high LH
poor ovarian reserve
What does a raised progesterone on day 21 suggest?
Rise in progesterone on day 21 indicates that ovulation has occurred, and the corpus luteum has formed and started secreting progesterone.
What is AMH a marker of?
Can be measured anytime as a marker of ovarian reserve.
high is good reserve, released by granulosa cells
Beyond hormones, what further Ix can be done in secondary care? (imaging)
- Ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus
- Hysterosalpingogram to look at the patency of the fallopian tubes
- Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis
What does a Hysterosalpingogram involve?
Through cervix contrast in put into uterine cavity and Fallopian tubes.
Xray images shows obstruction:
- tubal cannulation can open it up during procedure
Small risk of infection so:
- give Abx prophylactically if Hx of infection / dilation
- screen for chalmydia and gonorrhoea before the procedure
