Assessment of Infertility Flashcards
name 6 possible factors contributing to infertility?
older women rise in increase in chlamydia infections increase in obesity increasing male factor infertility (reduced sperm quality, increase testicular cancer rate etc) increasing awareness of treatments change in expectations
what are the chances of getting pregnant?
at 6 months = 75%
at 12 months = 90%
at 2 years = 95%
what is infertility?
failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (in absence of a known reason) in a couple who have never had a child
primary vs secondary infertility?
primary = couple never conceived secondary = couple previously conceived although pregnancy may not have been successful (e.g miscarriage, ectopic etc)
what factors can increase chances of conception?
woman under 30 previous pregnancy less than 3 years trying to conceive intercourse occurring around ovulation womans BMI between 18.5-30 caffeine intake less than 2 cups of coffee per day no use of recreational drugs both partners non smokers
when does age of mother peak and dip for conception?
peaks around 20-24 (around up to 30)
lowest after 40 (very common to miscarry if over 45)
what is anovulatory infertility?
infertility due to lack of ovulation
physiological causes for anovulatory infertility?
before puberty
pregnancy
lactation
menopause
gynaecological causes for anovulatory infertility?
hypothalamic (anorexia,bulimia, excessive exercise)
pituitary (hyperprolactinaemia, tumours, sheehan syndrome)
ovarian (PCOS, premature ovarian failure)
other causes of anovulatory infertility?
systemic disorder (chronic renal failure) endocrine disorder (testosterone secreting tumours, congenital adrenal hyperplasia, thyroid) drugs (Depo-Provera, explanon, OCP)
clinical features of anorexia?
BMI <18.5 loss of hair increase lanugo low pulse and BP anaemia
endocrine features of anorexia?
low FSH
low LH
low oestradiol
what can cause polycystic ovary syndrome?
inherited
weight gain can exacerbate
clinical features of polycystic ovary syndrome?
obesity
hirtutism or acne
cycle abnormalities
infertility
endocrine features of polycystic ovary syndrome?
high free androgens
high LH
impaired glucose tolerance
how is polycystic ovary syndrome diagnosed?
2 out of:
- chronic anovulation
- polycystic ovaries
- hyperandrogenism (clinical or biochemical)
what can cause premature ovarian failure?
idiopathic genetic (turners syndrome, fragile X) chemotherapy radiotherapy oophorectomy
what are the clinical and endocrine features of premature ovarian failure?
hot flushes night sweats atrophic vaginitis high FSH high LH low oestradiol
name 3 infective causes of tubal disease in females
pelvic inflammatory disease (chlamydia and other STD etc) transperitoneal spread of appendicitis, intra-abdominal abscess etc following procedure (IUCD insertion, hysteroscopy, HSG)
name 6 non-infective causes of tubal disease in females?
endometriosis surgical (sterilisation, ectopic pregnancy) fibroids polyps congenital salpingitis isthmica nodosa
what are the clinical features of hydrosalpinx due to pelvic inflammatory disease?
abdominal/pelvic pain febrile vaginal discharge dyspareunia cervical excitation menorrhagia dysmenorrhoea infertility ectopic pregnancy
what is endometriosis?
presence of endometrial glands outside uterine cavity
aetiology of endometriosis?
retrograde menstruation is most likely cause
altered immune function
abnormal cellular adhesion molecules
genetic
what are the clinical features of endometriosis?
dysmenorrhoea (usually before menstruation) dyspareunia menorrhagia painful defaecation chronic pelvic pain uterus may be fixed and retroverted scan may show characteristic "chocolate cysts" on ovary infertility asymptomatic
endocrine causes of male infertility?
hypogonadotropic hypogonadism
hypothyroidism
hypoprolactinaemia
diabetes
genetic causes of males infertility?
kleinfelter syndrome
Y chromosome deletion
immotile cilia syndrome
other physical causes of male infertility?
erectile dysfunction ejaculatory failure testicular torsion varicocele undescended testes heat, radiation, tight clothing around testes obstructive
drugs causing male infertility?
smoking (tobacco and marijuana)
anabolic steroids
testosterone supplements
give 4 non-obstructive causes of male infertility
XXY genotype chemotherapy radiotherapy undescended testes idiopathic
what are the clinical and endocrine features of non-obstructive male infertility?
low testicular volume reduced secondary sexual characteristics vas deferens present high LH, FSH low testosterone
name 3 obstructive causes of male infertility
congenital absence (cystic fibrosis)
infection
vasectomy
what are the clinical and endocrine features of obstructive male infertility?
normal testicular volume
normal secondary sexual characteristics
vas deferens may be absent
normal LH, FSH and testosterone
important aspects of female examination in fertility clinic?
BMI
general exam assessing body hair distribution and galactorrhoea
pelvic examination assessing for uterine and ovarian abnormalities/tenderness/mobility
important aspects of male examination in fertility clinic?
BMI
general exam
genital examination assessing size/position of testes, penile abnormalities. presence of vas deferens and presence of varicoceles
what investigations can be done in females?
endocervical swab for chalmydia
cervical smear if due
bloods for rubella immunity
midluteal progesterone level
test of tubal patency (hysterosalpingiogram or laparoscopy)
others if indicated (hysteroscopy, US, endocrine profile and chromosomes)
how is mid luteal progesterone level measured?
day 21 of 28 day cycle or 7 days prior to extended period in longer cycles
progesterone > 30nml/L is suggestive of ovulation
when is a hysterosalpingiogram used to assess tubal patency?
if no known risk factors tubal/pelvic pathology
if laparoscopy contraindicated (i.e obesity, previous pelvic surgery, crohns)
when is a laparoscopy used to test tubal patency?
possible tubal/pelvic disease (e.g PID)
known previous pathology (e.g ectopic pregnancy, ruptured appendix, endometriosis)
history suggestive of pathology
previously abnormal HSG
when is a hysteroscopy used?
only used in cases where suspected or known endometrial pathology (i.e uterine septum, adhesions, polyps)
when might a pelvic US be used?
when abnormality on pelvic examination (enlarged uterus/adnexal mass)
when required from other investigations (polyp seen at HSG etc)
what endocrine tests should be done if anovulatory or infrequent periods?
urine HCG prolactin TSH testosterone and SHBG LH, FSH and oestradiol
what endocrine tests should be done if hirsutism present?
testosterone
SHBG
what endocrine tests should be done if amenorrhoea be done?
endocrine profile (as in an anovulatory cycle) chromosome analysis
investigations in male infertility?
history
examination (general and genitalia)
semen analysis - twice over 6 weeks apart
what semen parameters are commonly used in semen analysis?
volume pH concentration motility morphology WBC
what assessments are done is semen analysis is abnormal?
LH and FSH
testosterone
prolactin
thyroid function
what assessments should be done if semen analysis is severely abnormal?
endocrine profile (same as abnormal semen)
chromosomal analysis and Y chromosome microdeletions
screen for CF
testicular biopsy
what assessment should be done if an abnormality if found on male genital examination?
scrotal US
