Causes and Treatments of Subfertility Flashcards
1
Q
Define ‘Infertility’ - does this apply to everyone?
A
- Failure to achieve pregnancy after two years of frequent unprotected intercourse
- Six months for secondary infertility and women above 36 years old
2
Q
When is infertility diagnosed in someone over 36 years of age?
A
six months
3
Q
For couples who have had a pregnancy before, regardless of the outcome, if they cannot conceive within … they should be offered consultations and investigations to help with fertility
A
6 months
4
Q
Infertility affects 1 in every … couples
A
1 in every 6 couples (15%)
5
Q
What percentage of couples achieve pregnancy after one year of trying?
A
84%
6
Q
What percentage of couples achieve pregnancy after two years of trying?
A
92%
7
Q
What percentage of couples achieve pregnancy after three years of trying?
A
94%
8
Q
New NICE guideline - Infertility definition: Part 1
A
“The period of time people have been trying to conceive without success after which formal investigation is justified and possible treatment implemented”
9
Q
New NICE Guideline - Infertility Definition: Part 2
“If a woman has not conceived after a …, offer further clinical assessment and investigation, along with her partner”
A
“If a woman has not conceived after a year, offer further clinical assessment and investigation, along with her partner”
10
Q
New NICE Guideline - Infertility Definition: Part 3
“If a woman is using AI has not conceived after … cycles of treatment, offer further clinical assessment and investigation. When AI is using partner sperm, the referral should… ”
A
“If a woman is using AI has not conceived after 6 cycles of treatment, offer further clinical assessment and investigation. When AI is using partner sperm, the referral should include her partner”
11
Q
New NICE Guideline - Refer early for specialist consultation:
- Women aged >… years
- There is a known cause of … or history of … factors
- Investigations show there is no chance of pregnancy with expectant management
A
- Women aged >36 years
- There is a known cause of infertility or history of predisposing factors
- Investigations show there is no chance of pregnancy with expectant management
12
Q
Causes of Infertility
- Female Factor …%
- Male Factor …%
- Combined …%
- Unexplained …%
- Other causes …%
A
- Female Factor 30%
- Male Factor 30%
- Combined 10%
- Unexplained 25%
- Other causes 5%
13
Q
Female Factors - Causes of Infertility
- Ovulation disorder: PCO (…%), P…, …pituitarism, RadioChemo Tx
- Tubal blockage: P.., e…, … pregnancy
- …-related: Limited … Reserve
- … problems: S…e, p…, f…
A
- Ovulation disorder: PCO (80%), POF, Hypopituitarism, RadioChemo Tx
- Tubal blockage: PID, endometriosis, ectopic pregnancy
- Age-related: Limited Ovarian Reserve
- Uterine problems: Synechiae, polyp, fibroid
14
Q
BASIC INFERTILITY WORK UP
- HISTORY AND EXAMINATION OF …
- LEVELS OF …,… AND O…, P… TFT ON DAY 2 OR 3
- MID LUTEAL … (regular cycles)
- … SWAB & R…
- H…
- … ULTRASOUND
A
- HISTORY AND EXAMINATION OF BOTH PARTNERS
- FSH LH AND OESTRADIOL PROLACTIN TFT ON
- DAY 2 OR 3
- MID LUTEAL PROGESTERONE (regular cycles)
- CHLAMYDIA SWAB & Rubella
- HSG
- PELVIC ULTRASOUND
15
Q
What is shown here?
A
Female Ovulatory Cycle
16
Q
If FSH is high, it means a women has a … ovarian reserve
A
If FSH is high, it means a women has a low ovarian reserve
17
Q
Ovulation tests in pharmacies are testing the levels of
A
LH
18
Q
- Part of the test for ovarian reserve is to count the number of …
- We also test for amount of …
A
- follicles
- test for amount of AMH (Anti Mullerian Hormone) - best prediction of ovarian reserve
19
Q
Anti Mullerian Hormone
- Produced by the … cells
- … production in pre-antral and small antral stages
- Levels of AMH … through monthly periods but … with age.
- Increasing age means a decreased …
- Increasing age means a decreasing … level
- Higher AMH levels predict a … response
- Lower AMH levels predict a … response
A
- Produced by the Granulosa cells
- High production in pre-antral and small antral stages
- Levels of AMH constant through monthly periods but declines with age.
- Increasing age means a decreased follicle pool
- Increasing age means a decreasing AMH level
- Higher AMH levels predict a good response
- Lower AMH levels predict a poor response
20
Q
- … AMH levels predict a good response
- … AMH levels predict a poor response
A
- Higher AMH levels predict a good response
- Lower AMH levels predict a poor response
21
Q
The most useful investigations for women - Trying to Conceive
- … … Assessment
- Day …-… FSH, LH, o…, A..
- Pelvic … & antral … count
A
-
Ovarian Reserve Assessment
- Day 2-3 FSH, LH, oestradiol, AMH
- Pelvic Ultrasound & antral follicle count
22
Q
What is this graph showing?
A
Effect of female age on fertility potential
23
Q
What is Tubal Patency?
A
Tubal patency is when a woman’s fallopian tubes are not blocked
24
Q
How do we test for tubal patency?
A
- HSG
- Tubal patency is determined by an x-ray test called a hystero-(uterus)salpingo-(fallopian tube)graphy (HSG). HSG is a standard radiological imaging study that is used to determine if the fallopian tubes are open and free of disease
25
What is a HyCoSy test?
* It is a Fallopian Tube Patency Test
* A HyCoSy fertility scan is a short procedure to detect whether the fallopian tubes are damaged or blocked.
* It is sometimes called a Tubal Patency Test or a Dye Test and can be a substitute for a HSG (Hysterosalpingography) or Laparoscopy and Dye, without the use of X-rays.
26
The gold standard test for tubal patency is ...
**laparoscopy and dye**
27
_Semen Analysis: Normal Results_
* Count \> 15 x 106 / ml
* Progressive Motility - 32%, Total Motility \> ...%
* Abnormal forms \< ...%
* Volume ... - ... mls
* Count \> **15 x 106 / ml**
* Progressive Motility - **32**%, Total Motility \> **40**%
* Abnormal forms \< **96%**
* Volume **1.5-6** mls
28
_Recent NICE Guidelines - Fertility treatment / Ovarian Reserve_
* AMH (...-... Hormone) & not ...
* No fund for ...
* No ... age
* Upper age ... years
* Treat ... women
* Treat ... couples
* AMH (**Anti-Mullarian** Hormone) & not **FSH**
* No fund for **IUI**
* No **lower** age
* Upper age **42** years
* Treat **single** women
* Treat **same sex** couples
29
_New NICE Guideline - Unexplained Infertility_
1. Do not offer ...
2. Do not offer ... ... stimulation
3. Offer ... for women who have not conceived after ... years
1. Do not offer **IUI**
2. Do not offer **oral** **ovulation** stimulation
3. Offer **IVF** for women who have not conceived after **2** years
30
_New NICE Guideline - IVF and age_
* Offer ... full IVF cycles to women under 40 year
* Offer ... full cycle to women aged 40-42 years provided:
* 1.... had IVF before
* 2.No evidence of ... ... reserve
* 3.Discuss ... of IVF & pregnancy at this age
* Offer **3** full IVF cycles to women under 40 year
* Offer **one** full cycle to women aged 40-42 years provided:
* 1.**Never** had IVF before
* 2.No evidence of **low ovarian reserve**
* 3.Discuss **implications** of IVF & pregnancy at this age
31
_New NICE Guideline - Clomid & FSH Injections_
* Clomid & FSH injections:
* 1.No association with ...
* 2.No association with ... in ... born after OI
* 3.... term ... outcomes in women & children is still awaited
* Clomid & FSH injections:
* 1.No association with **cancer**
* 2.No association with **cancer** in **children** born after OI
* 3.**Long** term **health** outcomes in women & children is still awaited
32
_New NICE Guideline - Couples having IVF_
* Chance of ... ... falls with rising female age
* IVF is more effective in women who ...
* Absolute risks of long term adverse outcomes in children born as a result of IVF are ...
* Chance of **Live Birth** falls with rising female age
* IVF is more effective in women who **achieved pregnancy before**
* Absolute risks of long term adverse outcomes in children born as a result of IVF are **low**
33
_KSS Funding Criteria - Fertility Treatment_
* Female age less than ... year
* AMH level at ... or above
* BMI ...-...
* No ... ... including ... children
* Both non-...
* ... induction when indicated
* No IUI except for heterosexual couples who cannot achieve ...
* No fund for treatment involving the use of ... eggs or sperm or ...
* ... fresh IVF & ... frozen treatment cycles
* Female age less than **40** year
* AMH level at **5** or above
* BMI **19-29.9**
* No **existing** **children** including **adopted** children
* Both **non-smoker**
* **Ovulation** induction when indicated
* No IUI except for heterosexual couples who cannot achieve **intercourse**
* No fund for treatment involving the use of **donor** eggs or sperm or **surrogacy**
* **2** fresh IVF & **2** frozen treatment cycles
34
_Metformin v Placebo for women with PCOS_
* RCT 143 anovulatory PCOS, mean BMI 38 kgm-2
* Significant increase in number of ..., and ... in BMI and waist circumference in both groups
* No difference in ... rate between the groups Improvements seen in those who ... in each group
* Tang et al, Human Reproduction 2006; 21: 80 - 89
* RCT 143 anovulatory PCOS, mean BMI 38 kgm-2
* Significant increase in number of **cycles**, and **fall** in BMI and waist circumference in both groups
* No difference in **ovulation** rate between the groups Improvements seen in those who **lost weight** in each group
* Tang et al, Human Reproduction 2006; 21: 80 - 89
35
PCOS - Metformin and Clomiphene?
* Two very large RCTs have failed to show any benefit from Metformin
* Clomiphene alone results in highest live birth rate. No benefit combining with Metformin.
36
_CC and/or metformin alone or in combination - PCOS_
* Which is superior? Use Both?
* **CC superior to metformin and combination confers no advantage in achieving live birth**
37
_Metformin for women with PCOS_
* ... oocyte glucose and pyruvate consumption and ... lactate production in oocytes from PCOs
* Associated with abnormal oocyte ...
* Metformin therapy improves ... in eggs
* ... live birth and lower OHSS with IVF
* **Increased** oocyte glucose and pyruvate consumption and **reduced** lactate production in oocytes from PCOs
* Associated with abnormal oocyte **karyotypes**
* Metformin therapy improves **metabolism** in eggs
* **Increased** live birth and lower OHSS with IVF
38
_In-Vitro Fertilisation (IVF)_
IVF (In Vitro Fertilisation), is an assisted fertility treatment where an egg cell is fertilised by a sperm cell outside of a body in a laboratory.
39
_IVF or ICSI - standard long protocol - how are they different?_
**ICSI differs from IVF as each egg is individually injected with a single sperm, bypassing the stage where the sperm has to naturally penetrate the egg.**
40
What are these injections for?
Ovarian stimulation (Gonal-F is used when a woman desires pregnancy and her ovaries can produce a follicle but hormonal stimulation is not sufficient to make the follicle mature.)
41
_Egg Collection - IVF_
* You'll be sedated and your eggs will be collected using a needle that's passed through the vagina and into each ovary under ultrasound guidance.
* This is a minor procedure that takes about 15 to 20 minutes.
* Some women experience cramps or a small amount of vaginal bleeding after this procedure.
42
_Fertilising the eggs - IVF_
* The collected eggs are mixed with your partner's or the donor's sperm in a laboratory. After 16 to 20 hours, they're checked to see if any have been fertilised.
* In some cases, each egg may need to be injected individually with a single sperm. This is called intra-cytoplasmic sperm injection or ICSI. The Human Fertilisation and Embryology Authority (HFEA) has more information about ICSI.
* The fertilised eggs (embryos) continue to grow in the laboratory for up to 6 days before being transferred into the womb. The best 1 or 2 embryos will be chosen for transfer.
43
_ICSI (Intra-cytoplasmic sperm injection) - what is this?_
* ICSI is an effective treatment for men with infertility. It's performed as part of in vitro fertilisation (IVF). It involves the sperm being injected directly into the egg. Some men may need their sperm to be surgically extracted first.
44
_Surgical Sperm Retrieval_
* When is this done?
* SSR is intended to help men who have no sperm in their ejaculate or less commonly for men with extremely low quality sperm
45
_Embryo development and transfer - IVF_
* The fertilised eggs (embryos) continue to grow in the laboratory for up to 6 days before being transferred into the womb. The best 1 or 2 embryos will be chosen for transfer.
* A few days after the eggs are collected, the embryos are transferred into the womb. This is done using a thin tube called a catheter that's passed into the vagina.
46
_IVF treatment outcome_
* Overall pregnancy rate (PR) is ...%
* Overall Live Birth rate (LB) is ...%
* PR for women \< 35 year is ...%
* Live Birth rate for women \< 35 year is ...%
* Overall pregnancy rate (PR) is **53.5**%
* Overall Live Birth rate (LB) is **47.8**%
* PR for women \< 35 year is **60**%
* LB rate for women \< 35 year is **56.6**%
