assessment + management of infertility Flashcards
how many couples does infertility affect?
-it is a common condition affecting 1:6 couples
how has the incidence of infertility changed in the past 10 years?
-it’s doubled in the past 10 years
what is the WHO definition for infertility?
-failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse in a couple who have never had a child
what types of infertility are there?
Primary and secondary
what is primary infertility?
-the couple has never conceived
what is secondary infertility?
-couple previously conceived, although pregnancy may not have been successful e.g. miscarriage or ectopic pregnancy
what are some factors affecting pertility?
- women <30 years
- previous pregnancy
- <3 years trying to conceive
- intercourse occuring around ovulation
- womans BMI 18.5-30 m/kg
- both partners non smokers
- caffeine intake is less than 2 cups of coffee daily
- no use of recreational drugs
what are some common causes of secondary infertility?
- tubal disease
- gibroids
- endometriosis/ adenomyosis
- weight related
- age related
what are some physiological causes of anovulatory infertility?
- pre puberty
- pregnancy
- lactation
- menopause
what are some gynaecological conditions causing anovulatory infertility?
Hypothalmic: anorexia/ bulimia, excessive exercise
Pituitary: hyperprolactinaemia, tumours, Sheehan syndrome
Overy: PCOS, premature ovarian failure
is anorexia nervosa more common in males or females?
-females
what is the aetiology of anorexia nervosa?
- social cultural
- genetic
how does anorexia nervosa present?
- weight loss
- increased exercise
- withdrawal from friends
- amenorrhoea
- infertility
- low BMI (<18.5)
- loss of hair
- increased lanugo
- low pulse and BP
- anaemia
- dehydration
- reduced bone density
- muscle weakness and loss
is polycystic ovary syndome (PCOS) common?
-yes it is the commonest endocrine disorder in women
what is the aetiology of PCOS?
- its inherited
- weight gain exacerbates it
what are some clinical features of PCOS?
- obesity
- hirsutism
- acne
- menstrual cycle abnormalities
- infertility
what are some endocrine feature of PCOS?
- high free androgens
- high LH
- impaired glucose tolerance
how is PCOS diagnosed?
must score 2 out of three:
- chronic anovulation
- polycystic ovaries
- hyperandrogenism (clinical or biochemical)
what can cause premature ovarian failure?
- idiopathic
- chemotherapy
- radiotherapy
- genetic
- oophorectomy
what are the clinical features of premature ovarian failure?
- hot flushes
- night sweats
- atrophic vaginitis
- amenorrhoea
- infertility
what are some endocrine features of premature ovarian failure?
- high FSH
- high LH
- low oestradiol
what are some infective causes of Tubal disease?
- Pelvic inflammatory disease (chlamydia, gonorrhoea, other: anaerobes, syphilis, TB)
- transperitoneal spread: appendicitis, intra-abdominal abscess
- following procedure: IUCD insertion, hysteroscopy, HSG
what are some non infective causes of tubal disease?
- endometriosis
- surgical (sterilisation, ectopic pregnancies)
- fibroids
- polyps
- congenital
- salpingitis isthmica nodosa
what is hydrosalpinx?
-when a fallopian tube becomes filled with fluid due to injury or infection
what are clinical features of hydrosalpinx?
- abdominal/ pelvic pain
- fever
- vaginal discharge
- cervical excitation
- menorrhagia
- dysmenorrhea
- infertility
- ectopic pregnancy
what is endometriosis?
-it is an often painful disorder in which tissue similar to the tissue that normally lines the inside of your uterus — the endometrium — grows outside your uterus.
what are causes of endometriosis?
- retrograde menstruation (most likely)
- altered immune function
- abnormal cellular adhesion molecules
- genetic
what are some clinical features of endometriosis?
- dysmenorrhoea
- dysparenuia
- menorrhagia
- painful defecation
- chronic pelvic pain
- uterus may be fixed and retroverted
- scan may show characteristic ‘chocolate’ cysts on ovary
- infertility
- asymptomatic
what are some non obstructed causes of male infertility?
- chemotherapy
- radiotherapy
- undescended testes
- idiopathic
what are the endocrine features of non obstructive male infertility?
- high LH and FSH
- low testosterone
what are some causes of obstructive male infertility?
- congenital absence (e.g. cystic fibrosis)
- infection
- vasectomy
what are the endocrine feature for obstructive male infertility?
-normal LH, FSH and testosterone
what are investigations of infertility in females?
- endocervical swab for chlamydia
- cervical smear if due
- blood for rubella immmunity
- midluteal progesterone level
- test of tubal patency (hysterosalpingiogram or laparoscopy)
when is a hysteroscopy performed?
-only performed in cases where suspected or known endometrial pathology
when would a pelvic ultrasound be performed?
-when there is an abnormality on pelvic examination (e.g. enlarged uterus)
what are some infertility investigations in males?
- semen analysis (twice over 6 weeks apart)
- scrotal ultrasound
- LH, FSH, testosterone, prolactin, thyroid function (endocrine profile)
- chromosome analysis
- testicular biopsy
- screen for cystic fibrosis
what is lifestyle advice for a couplet trying to conceive?
- stop smoking
- achieve BMI between 18.5 and 30
- reduce alcohol
- try drink less caffeinated drinks
- stop taking recreational drugs
- stop methadone
does weight have an effect on miscarriage rate and fertility problems in women?
yes - overweight women have an increase in fertility problems and higher miscarriage rate
what are some examples of vitamin tablets that may be prescribed for pregnancy?
- folic acid
- vitamin D
when is folic acid given for pregnancy?
400mcg daily before pregnancy and throughout the first 12 weeks
what is the management of hypothalamic anovulation?
- Stabilise weight (BMI>18.5)
- Pulsatile GnRH to induce ovulation in hypothalamic amenorrhoea
- Gonodotrophin (FSH + LH) daily injections
(both need regular ultrasound monitoring of ovarian response)
what are symptoms of PCOS?
- irregular menstrual cycle
- hirsutism
- acne
- subfertility
- alopecia
- obesity
what biochemical markers are found in someone with PCOS?
- elevated serum LH (>10 IU/L)
- LH/ FSH ratio >2
- normal estradiol
- low progesterone
- normal or mildly elevated progesterone
- raised testosterone
what may be seen on a transvaginal USS of someone with PCOS?
-polycystic ovarian morphology
what is the treatment for PCOS?
first line= ovulation induction
this can be done using a number of treatments such as:
- Antioestrogens (clomifene citrate and tamoxifen)
- Aromatose inhibitors (letrozole)
second line= laparoscopic ovarian drilling
what is the risk of gonadotrophin therapy?
- multiple pregnancies
- ovarian hyperstimulation syndrome (OHSS) which is when the ovaries swell and become painful
what is the risk of laparoscopic ovarian diathermy?
-risk of ovarian destruction/adhesions resulting in mainly singleton pregnancies
what is hydrosalpinx?
when the fallopian tube becomes filled with fluid due to injury or infection
what is myosure instrument used for?
-removing polyps
what is a uterine septum?
-a condition where the uterus gets an extra wedge of tissue
