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
Hysteroscopy?
Only performed in cases where suspected or known endometrial pathology:
i.e. uterine septum, adhesions, polyp
