Causes and Treatments of Subfertility Flashcards
Define ‘Infertility’ - does this apply to everyone?
- Failure to achieve pregnancy after two years of frequent unprotected intercourse
- Six months for secondary infertility and women above 36 years old
When is infertility diagnosed in someone over 36 years of age?
six months
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
6 months
Infertility affects 1 in every … couples
1 in every 6 couples (15%)
What percentage of couples achieve pregnancy after one year of trying?
84%
What percentage of couples achieve pregnancy after two years of trying?
92%
What percentage of couples achieve pregnancy after three years of trying?
94%
New NICE guideline - Infertility definition: Part 1
“The period of time people have been trying to conceive without success after which formal investigation is justified and possible treatment implemented”
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”
“If a woman has not conceived after a year, offer further clinical assessment and investigation, along with her partner”
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… ”
“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”
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
- 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
Causes of Infertility
- Female Factor …%
- Male Factor …%
- Combined …%
- Unexplained …%
- Other causes …%
- Female Factor 30%
- Male Factor 30%
- Combined 10%
- Unexplained 25%
- Other causes 5%
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…
- Ovulation disorder: PCO (80%), POF, Hypopituitarism, RadioChemo Tx
- Tubal blockage: PID, endometriosis, ectopic pregnancy
- Age-related: Limited Ovarian Reserve
- Uterine problems: Synechiae, polyp, fibroid
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
- 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
What is shown here?
Female Ovulatory Cycle
If FSH is high, it means a women has a … ovarian reserve
If FSH is high, it means a women has a low ovarian reserve
Ovulation tests in pharmacies are testing the levels of
LH
- Part of the test for ovarian reserve is to count the number of …
- We also test for amount of …
- follicles
- test for amount of AMH (Anti Mullerian Hormone) - best prediction of ovarian reserve
What is this graph showing?
Effect of female age on fertility potential
How do we test for tubal patency?
- 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
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.
The gold standard test for tubal patency is …
laparoscopy and dye
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
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
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.
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.
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.
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.)
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.
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.
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.
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
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.
