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
What does Laparoscopy and Dye Test involve?
- Laparoscopy, then die is injected into uterus and this should be seen coming out of tube ends
- also assess and treat endometriosis and pelvic adhesions
When there is an ovulation problem, what are 6 treatment options?
- Weight loss for 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)
(not IVF)
What is Clomifene?
an anti-oestrogen (a selective oestrogen receptor modulator)
Given on day 2-6, it stop -ve oestrogen feedback on hypothalamus, resulting in greater GnRH and therefore greater FSH and LH release.
What is ovarian drilling?
Ovarian drilling involves laparoscopic surgery.
Punctures multiple holes in the ovaries using diathermy or laser therapy.
Improve the woman’s hormonal profile and result in regular ovulation and fertility.
What treatment is there for tubal factors of infertility?
- Tubal cannulation during a hysterosalpingogram
- Laparoscopy to remove adhesions or endometriosis
- In vitro fertilisation (IVF)
