8 - Infertility Flashcards
Infertility definition?
The failure to conceive after 12 months of unprotected intercourse
(isn’t really classified as a disease anymore)
How many couples are affected by infertility and what are the consequences?
1/4 couples
In 1st world countries is a largely emotional burden. In 3rd world countries there are more serious consequences (ostracised, poverty, death)
World fertility rate?
Declining - good as the current population growth is unsustainable (2.2)
Voluntary childlessness?
Increasing - 18% in NZ
Assessment of male infertility includes…
Semen analysis
- Count
- Motility
- Volume
- Total number of sperm
- Morphology
Normal: Count Motility Volume Total number of sperm Morphology
Count: 15 million/mL Motility: 40% Volume: 1.5mL Total number of sperm: 39 million in ejaculate Morphology: Only 4% normal morphology
Basic assessment of female fertility includes…
- Ovulation
- regularity of periods around 28 days
- E2 - day 12
- P4 - day 21
- FSH - day 2-4 (< 10 IU/I)
- AMH - age-related graph - Timing (not frequency) of intercourse
- low awareness of when they are ovulating - STIs
- 70% are a-symptomatic
6 leading causes of infertility in women and main treatments?
- Anovulation
> weight gain/loss
> drugs
2. PCOS > weight loss > letrozole > metformin (insulin sensitiser) > IVF
- Tubal disease
> surgery
> IVF - Cervical problems insemination
> rare
> IUI (intrauterine insemination) - Endometriosis
> Hormonal contraceptives
> Ablation - surgery/scar
> IVF - Premature menopause/Premature Ovarian Failure or rising FSH and decreasing AMH with age
> Donor egg (IVF) - No uterus (rare)
> surrogacy
3 most common causes of male infertility?
- Oligospermia
> ICSI (intra-cytoplasmic sperm injection)
> donor sperm if really bad - OATS (oligoasthenoteratospermia - low concentration, low motility and abnormal morphology)
> ICSI
> donor sperm - Azoospermia
Anovulation and treatment?
Often due to under or overweight
> first line of treatment is weight gain/loss
Drugs:
- GnRH
- Clomiphene citrate (selective estrogen receptor modulator»_space; produces more FSH to stimulate production of more oestrogen)
- Letrazole (unlike CC get more of a monofollicular growth - less likely to get twins)
> prevents conversion of androgens to oestrogen so brain produces more FSH
- FSH
Polycystic Ovarian Syndrome and common treatments?
- 10% of women
- Lots of medium sized follicles on US that don’t seem to complete development
- Infrequent or no periods
- Often a metabolic syndrome - overweight
- often increased androgens
> weight loss
letrozole
metformin (insulin sensitiser - part of metabolic syndrome)
IVF
Letrozole?
Aromatase inhibitor - prevents conversion of androgens to oestrogen. Then stimulates release of FSH and so oestrogen production
Tubal disease and common treatments?
- cysts
- tumors
- ectopic pregnancies
- blocked/damaged tubes
- adhesions (common)
- endometriosis
> surgery
IVF (bypasses the tubes)
Cervical problems
- aren’t very common
> Intra-uterine insemination (also often used for unexplained fertility problems)
Endometriosis?
- 10% of women affected
- > 30% of infertile women have some stage of endometriosis
> hormonal contraceptions
ablation - surgery/scaring
IVF
What are the 6 steps of IVF?
- Egg production is stimulated by hormone therapy
- Eggs are retrieved from the ovary
- A sperm sample is provided
- The eggs and sperm are combined to allow fertilisation
- The fertilised eggs are introduced into the uterus
- Embryo freezing
How are the ovaries stimulated in IVF?
a) Stimulation by FSH
b) Give GnRH antagonists to PREVENT ovulation (until follicles have grown to sufficient size/matured)
c) Stimulate ovulation by HCG or GnRH agonist
d) Give progesterone for luteal support (essential)
> essential as the fertility drugs have a negative effect on the endometrium
How do you track the IVF cycle?
- Transvaginal US scans (measure size of each follicle)
- Blood tests:
> estrogen (1000 units per follicle)
> progesterone (don’t want to see rise)
How does the success rate of IVF change with age?
Success rate is measured by the cumulative pregnancy rate from first fresh and subsequent frozen cycles.
Declines with age (50% > 25% by 40)
…
Time lapse photography and advantages?
Recent innovation - used to get the embryos/eggs out every day and check quality and grade by hand every day.
Photograph of every embryo is taken every 10 minutes
- not taking out incubator so undisturbed culture
- individual embryo tracking of cell division
- able to predict those with the best potential with algorithms
- provides full information
- no more single snapshot in time selection
Azoospermia causes and treatments?
No sperm
- Kallman’s Syndorme (no GnRH - FSH/LH)
- no spermatogenesis
- obstructive or vasectomy
- congenital absence of the VD (common in cystic fibrosis)
> donor insemination
TESA - testicular sperm aspiration/extraction + ICSI
Testicular sperm aspiration?
Number of methods
- aspirate fluid out of the epididymis (hope there’s sperm)
- testicular aspiration
- chunk of testis
ICSI
Intra-cytoplasmic sperm injection
- 2 needles; one to hold egg in place and one to hold and inject the sperm
- ‘chop’ the sperm tail to stop it moving and to de-stabilize the membrane
Unexplained fertility?
May be due to an unknown aetiology, fertilisation issue (at level of sperm and egg) or most commonly due to age
> mild ovarian stimulation with IUI (first line - cheaper)
IVF (10,000)
