Causes and treatments of subfertility Flashcards
Requirements for conception
Progressively motile normal sperm capable of reaching and fertilising the oocyte
Timely release of a competent oocyte
Free passage for the sperm to reach the oocyte and for the embryo to reach the uterus
A mature endometrium that allows implantation
What is infertility?
Inability to conceive after 2 years of frequent unprotected intercourse
Cumulative probability of pregnancy is 84%, 92% and 93% after 1,2,3 years
Reasonable to investigate after 1 year unless there is a concern
Infertility definition
The period of time people have been trying to conceive without success after which formal investigation is justified and possible treatment implemented
Causes of infertility
Unexplained 30%
Ovulatory 27%
Male factor 19%
Tubal 14%
Endometriosis 5%
Other factors 5% (uterine, endometrial, gamete or embryo defect)
Indications for early referral (female)
Aged over 35 years
Amenorrhoea/ oligomenorrhoea
Previous abdominal/ pelvic surgery
Previous PID/ STD
Abnormal pelvic examination
Indications for early referral (male)
Previous genital pathology
Previous STD
Significant systemic illness
Abnormal genital examination
Abnormal semen analysis
No reason
Primary testicular failure is the commonest cause for oligo/ azoospermia
Obstructive or non-obstructive azoospermia –> FSH, LH and T
Y chromosome microdeletion and cystic fibrosis if sperm count < 5 million
Female age
A woman’s fertility declines with age
This is due to the decline in oocyte number and quality rather than uterine receptivity
The increased rate of chromosomal abnormalities in the oocyte also results in higher aneuploidy and miscarriage rates
Female assessment
Screen for chlamydia and rubella
Ovarian reserve
- early follicular hormone level
- AMH
- AFC
Ovulation test
Tubal test
AMH (anti- mullarian hormone)
Produced by the granulosa cells of pre-antral and small antral stages
Level of AMH constant through monthly periods but declines with age
Higher AMH levels predict a good response
Lower AMH levels predict a poor response
Ovulation
Most women who have a regular menstrual cycle will be ovulating
BBT, ovulation detection kits, cervical mucous pattern, follicular tracking or mid- luteal phase
Tubal patency
Disease can be proximal (25%) or distal (75%)
PID secondary to chlamydia is the commonest cause of tubal damage
Risk of tubal damage
12% after one episode of pelvic infection
23% after two episodes
54% after three episodes
Other causes of tubal patency
Septic abortion
Ruptured appendix
Pelvic surgery
Ectopic pregnancy
Hysterosalpingogram
Done 2-5 days after menstruation
Antibiotics should be given to prevent the flare up of infection if H/O PID
The overall risk of infection is approximately 1%
In high risk population this can rise to 3%
HSG advantages
Relative safety
Ease of use
Delineation of the uterine cavity and fallopian tubes
HSG disadvantages
Inability to assess the pelvic peritoneum
Hysterosalpingo-contrast-ultrasonography
Similar to HSG
No radiation so relatively safer
Ovarian and uterine assessment is possible
Time consuming and requires training
Laparoscopy and dye
Invasive procedure with inherent risks of visceral injury to the patient
More sensitive and specific
Chance to diagnose and treat endometriosis and adhesions
Uterine abnormality
Adhesions, polyps, submucous fibroids and septae are estimated to be a factor in 10-15% of couples seeking treatment
HSG, TVS and hysteroscopy
Hysteroscopy is undoubtedly better than HSG and TVS at detecting abnormalities
Ovulation induction
Clonid for women who have PCO
Anti-oestrogen effect on hypothalamic pituitary axis
FSH injections for resistant PCO or hypogonadotrophic hypogonadism
Risk of multiple pregnancy
Monitor 1st cycle using USS
IUI treatment usual indications
Unexplained
Mild male factor
Mild endometriosis
IUI treatment
Less stress
Less invasive
Less tech
Cheap
NICE guidelines
Do not offer IUI for couples who have unexplained infertility
IUI for single women, same sex couples or heterosexual couple who have problem with intercourse
IVF for couples who have unexplained infertility
IVF for
Tubal damage
Low sperm
Unexplained infertility
Low ovarian reserve
IVF LBR
Depends on female partner’s age
Varies from one unit to another
National average 30-35% <35 year old
