Assessment of infertility Flashcards
Causes of (secondary) Infertility?
tubal disease
fibroids
endometriosis/adenomyosis
weight related
age related
What is infertility?
Infertility: failure to achieve a clinical pregnancy after 12 months of more of regular unprotected sexual intercourse (in absence of known reason) in a couple who have never had a child (WHO definition)
* Infertility is a disease as causes considerable psychological distress
* Either primary (couple never conceived) or secondary (couple previously conceived, although pregnancy may not have been successful e.g. miscarriage or ectopic pregnancy).
Factors affecting Fertility?
Increased Chance Conception
* Woman aged under 30 years
* Previous pregnancy
* Less than three years trying to conceive
* Intercourse occurring around ovulation
* Woman’s body mass index (BMI) 18.5 – 30m/kg2
* Both partners non-smokers
* Caffeine intake less than two cups of coffee daily
* No use of recreational drugs
Anovulatory Infertility reasons?
Physiological: before puberty, pregnancy, lactation, menopause
Gynaecological Conditions:
Hypothalmic: anorexia/bulimia, excessive exercise,
Pituitary: hyperprolactinaemia, tumours, Sheehan syndrome
Ovarian: PCOS (plycyctic ovary syndrome), premature ovarian failure
*Others: *
Systematic disorder: e.g. chronic renal failure.
Endocrine disorder: e.g. testosterone secreting tumours, congenital adrenal hyperplasia, thyroid
Drugs: e.g. depo-provera, explanon, OCP
Polycystic Ovary Syndrome?
Prevalence: commonest endocrine disorder in women (20-33%)
Aetiology: inherited condition, weight gain exacerbates condition
Clinical Features: obesity, hirsutism or acne, menstrual cycle abnormalities and infertility
Endocrine features: high free androgens, high LH, impaired glucose tolerance
Diagnosis: score 2 out of three:
chronic anovulation
polycystic ovaries
hyperandrogenism (clinical or biochemical)
Premature Ovarian Failure?
Prevalence:1% before age 40 years
Aetiology: idiopathic, genetic (Turner’s syndrome, fragile X), chemotherapy, radiotherapy, oophorectomy
Clinical Features: hot flushes, night sweats, atrophic vaginitis, amenorrhoea, infertility
Endocrine Feature: high FSH, high LH, low oestradiol
Tubal Disease Causes?
Infective
* Pelvic inflammatory disease (chlamydia, gonorrhoea, other: anaerobes, syphilis, TB)
* transperitoneal spread: appendicitis, intra-abdominal abscess
* following procedure: IUCD insertion, hysteroscopy, HSG
Non-infective
* endometriosis
* surgical (sterilisation, ectopic pregnancies)
* fibroids
* polyps
* congenital
* salpingitis isthmica nodosa
Hydrosalpinx (expand and inflamed fallopian tube due to fluid blockage) due to Pelvic Inflammatory Disease?
Clinical Features: abdominal/pelvic pain febrile
* vaginal discharge dyspareunia
* cervical excitation menorrhagia
* dysmenorrhoea
* infertility
* ectopic pregnancy
Endometriosis?
Prevalence: approx. 20% (10% menstruating women, 30% women with infertility)
Definition: presence of endometrial glands outside uterine cavity
Aetiology: Retrograde menstruation is most likely cause, altered immune function, abnormal cellular adhesion molecules, genetic
*Clinical Features: *dysmenorrhoea (classically before menstruation), dysparenuia, menorrhagia, painful defaecation, chronic pelvic pain, uterus may be fixed and retroverted, scan may show characteristic ‘chocolate’ cysts on ovary, infertility, asymptomatic
BEST DIAGNOSIS- Biobsy
Male Infertility?
- Male factors are a major cause of infertility ( primary cause in 20-30% and contributing cause in 20%).
- Approx. 30-50% of male infertility is idiopathic.
- Environmental and lifestyle factors are risk factors (occupational, smoking, alcohol, obesity).
Non-Obstructive testicles?
Clinical Features:
low testicular volume
reduced secondary sexual characteristics
vas deferens present
Endocrine features:
High LH, FSH and low testosterone
Obstructive testicles?
Obstructive: e.g. congenital absence (cystic fibrosis), infection, vasectomy
Clinical Features:
normal testicular volume
normal secondary sexual characteristics
vas deferens may be absent
Endocrine features:
Normal LH, FSH and testosterone
Investigation of Infertility?
History: infertility history, gynaecology, andrology, sexual history, social history, PMH, PSH, POH
Examination of female:
BMI
General examination, assessing body hair distribution, galactorrhoea
Pelvic examination, assessing for uterine and ovarian abnormalities/tenderness/mobility
Examination of male:
BMI
General examination
Genital examination, assessing size/position testes, penile abnormalities, presence vas deferens, presence varicoceles
Investigation of Female?
- endocervical swab for chlamydia
- cervical smear if due
blood for rubella immunity - midluteal progesterone level (day 21 of 28 day cycle or 7 days prior to expected period in prolonged cycles), progesterone > 30nmol/l suggestive ovulation
- Test of tubal patency: hysterosalpingiogram (HSG) /hycosy or laparoscopy
- Others if indicated: e.g. hysteroscopy, ultrasound scan, endocrine profile and chromosomes
Test of Tubal Patency?
- HSG/Hycosy
- Laparoscopy
Hysterosalpingography (HSG)/Hycosy?
if nil known risk factors tubal/ pelvic pathology
- laparoscopy contraindicated
i.e. obesity, previous pelvic surgery, Crohn’s disease
Laparoscopy?
- possible tubal/pelvic disease: e.g.PID (Pelvic inflammatory disease)
- known previous pathology: e.g. ectopic pregnancy, ruptured appendix, endometriosis
- history suggestive of pathology: e.g. dysmenorrhoea, dysparunia
- previously abnormal HSG
Hysteroscopy?
Only performed in cases where suspected or known endometrial pathology:
i.e. uterine septum, adhesions, polyp
Pelvic Ultrasound?
- perform when abnormality on pelvic examination: e.g. enlarged uterus /adnexal mass
- when required from other investigations: e.g. possible polyp seen at HSG
Assessments for endocrine profile and chromosomes?
If anovulatory cycle or infrequent periods:
Urine HCG
Prolactin
TSH
Testosterone and SHBG
LH, FSH and oestradiol
If hirsute:
Testosterone and SHBG
If* amenorrhoea*:
endocrine profile (as in anovulatory cycle)
chromosome analysis
Assessments: male?
If abnormal semen analysis:
LH and FSH
Testosterone
Prolactin
Thyroid function
If severely abnormal semen analysis/ azoospermic
* endocrine profile (as in abnormal semen)
* chromosome analysis and Y chromosome microdeletions
* screen for cystic fibrosis
testicular biopsy
If* abnormality on genital examination*
scrotal ultrasound
Summary
Infertility is common disease
Incidence of infertility is increasing
Various life-style factors can influence fertility
Causes varied, often both male and female factor
Investigate at designated clinic
Assessment includes history and examination of both male and female
Initial investigations include assessment ovulation, tubal patency and semen analysis
Other investigations depend on results of initial investigations
Prompt investigation and appropriate referral allows advice and treatment to help optimise their chance of pregnancy
