Assessment of Infertility Flashcards
How common is infertility?
Affects 1:6 couples (15%) = about half of these couples will conceive either spontaneously or with relatively simple advice/treatment
How much of the population require more complex treatment for infertility?
8% remain subfertile and require more in-depth treatment
What are some factors linked with the rise on infertility?
Older women, rise in chlamydia, increase in obesity, increasing male factor infertility, increasing awareness of treatment, change in expectations
What are the cumulative conception rates for spontaneous pregnancy?
75% at 6 months, 90% at 12 months, 95% at two years
What is infertility defined as?
Failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sex (in absence of known reason) in a couple who have never had a child
What are the types of infertility?
Primary = couple have never conceived Secondary = couple conceived, although pregnancy may not have been successful (e.g miscarriage)
Why is infertility classed as a disease?
It causes considerable psychological distress
What are some factors that increase the likelihood of successful spontaneous pregnancy?
Women aged <30, previous pregnancy, <3 years trying to conceive, intercourse occurring around ovulation, woman/s BMI 18.5-30, both partners non-smokers, caffeine intake <2 cups of coffee a day, no use of recreational drugs
What are physiological causes of anovulatory infertility?
Before puberty, pregnancy, lactation, menopause
What are some gynaecological conditions that cause anovulatory infertility?
Hypothalamic = anorexia/bulimia, excessive exercise Pituitary = hyperprolactinaemia, tumours, Sheehan's Ovarian = PCOS, premature ovarian failure
What are some general causes of anovulatory infertility?
Chronic renal failure, testosterone-secreting tumours, congenital adrenal hyperplasia, thyroid, drugs (Depo-Provera, explanon, OCP)
How common is anorexia nervosa?
Affects 1% of population = more common in women, unknown aetiology
What are some features of anorexia nervosa?
Low BMI (<18.5), loss of hair, increased lanugo, low pulse and BP, anaemia Endocrine features = low FSH, LH and oestradiol
How common is polycystic ovary syndrome (PCOS)?
Most common endocrine disorder in women (20-33%) = usually inherited, exacerbated by weight gain
What are some features of polycystic ovary syndrome?
Obesity, hirsutism or acne, cycle abnormalities, infertility
Endocrine features = high free androgens, high LH, impaired glucose tolerance
How is polycystic ovary syndrome diagnosed?
Score of 2 out of three of the following = chronic anovulation, polycystic ovaries, hyperandrogenism
What are some causes of premature ovarian failure?
Idiopathic, chemo/radiotherapy, oophorectomy
Genetic = missing X chromosome in Turner’s syndrome, fragile X
What are the features of premature ovarian failure?
Hot flushes, night sweats, atrophic vaginitis
Endocrine features = high FSH, high LH, low oestradiol
What are some infective causes of tubal disease?
Chlamydia, gonorrhoea, anaerobes, syphilis, TB
Spread from appendicitis/intra-abdominal abscess
Following IUCD insertion, hysteroscopy or HSG
What are some non-infective causes of tubular disease?
Endometriosis, surgical (sterilisation, ectopic pregnancy), fibroids, polyps, congenital, salpingitis isthmica nodosa
What are some symptoms of a hydrosalpinx due to pelvic inflammatory disease?
Abdominal/pelvic pain, vaginal discharge, dyspareunia, cervical excitation, dysmenorrhoea, infertility, ectopic pregnancy
How common is endometriosis?
Affects about 20% = 10% of menstruating women, 30% of women with infertility
What is endometriosis?
Presence of endometrial glands outside uterine cavity
What causes endometriosis?
Most likely due to retrograde menstruation
May be genetic, or due to altered immune function or abnormal cellular adhesion
What are the clinical features of endometriosis?
Dysmenorrhoea (classically before menstruation), dyspareunia, painful defaecation, menorrhagia, chronic pelvic pain, fixed and retroverted uterus, “chocolate” cysts on ovary, infertility, asymptomatic in some
What are some pre-testicular causes of male infertility?
Endocrine = hypogonadotropic hypogonadism, hypothyroidism, hyperprolactinaemia, diabetes Coital = erectile dysfunction, ejaculatory failure
What are some testicular causes of male infertility?
Genetic = Klinefelter syndrome, Y chromosome deletion, immotile cilia syndrome
Congenital = cryptorchidism, infective, antispermatogenic agents
Torsion, varicocele, immunological
What are some post-testicular (obstructive) causes of male infertility?
Epididymal = congenital, infective Vasal = CF, vasectomy, ejaculatory duct obstruction, accessory gland infection
What drugs can cause male infertility?
Alcohol, tobacco, marijuana, testosterone supplements, SSRI antidepressants, cocaine
How do non-obstructive causes of male infertility present?
Low testicular volume, reduced secondary sexual characteristics, vas deferens present, high LH and FSH, low testosterone
How do obstructive causes of male infertility present?
Normal LH, FSH and testosterone, normal testicular volume, normal secondary sexual characteristics, vas deferens may be absent
How are couples suffering from infertility seen in clinic?
Seen as a couple = take infertility history, gynaecology, andrology, sexual history, social history, PMH, PSH and POH
How are females examined for infertility?
BMI, general examination (assessing body hair distribution, galactorrhoea), pelvic examination
How are males examined for infertility?
BMI, general examination, genital examination
What investigations are done in females?
Endocervical swab for chlamydia, cervical smear if due, blood for rubella immunity
How is the midluteal progesterone level investigated in a woman?
Day 21 of 28 day cycle or 7 days prior to expected period in prolonged cycles, progesterone >30nmol/L suggests ovulation
What are the tests for tubal patency in females, and when are they indicated?
Hysterosalpiniogram = if no known risk factors for tubal/pelvic pathology, laparoscopy contraindicated Laparoscopy = possible tubal/pelvic disease, known previous pathology, history suggestive of pathology, previous abnormal HSG
When is hysteroscopy performed to investigate infertility in females?
In cases where there is known/suspected endometrial pathology
When is a pelvic US done to investigate infertility in women?
When there is an abnormality on the pelvic examination, or when indicated by other investigations
What endocrine profile is done to investigate anovulatory cycles and infrequent periods?
Urine HCG, prolactin, TSH, testosterone and SHBG, LH, FSH, oestradiol
What endocrine profiles are done for hirsute females and those with amenorrhoea?
Hirsute = testosterone and SHBG Amenorrhoea = same profile as for anovulatory cycles, chromosome analysis
How should semen analysis be carried out?
Two samples taken over six weeks apart
What are the normal parameters for semen?
Volume >1.5ml, pH between 7.2-7.8, concentration >15x10^6/ml, motility >50%, morphology >4% with normal morphology, WBC <1x10^6/ml
What endocrine profile should be done for a male with abnormal semen analysis?
LH, FSH, testosterone, prolactin, thyroid function
What investigations should be done in a man with severely abnormal semen analysis or who is azoospermic?
Endocrine profile as for abnormal semen profile, chromosome analysis and Y chromosome microdeletions, screen for CF, testicular biopsy
When should a scrotal US be done?
If the genital examination of the male was abnormal
