Causes and treatments of subfertility Flashcards

1
Q

Requirements for conception

A

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

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2
Q

What is infertility?

A

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

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3
Q

Infertility definition

A

The period of time people have been trying to conceive without success after which formal investigation is justified and possible treatment implemented

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4
Q

Causes of infertility

A

Unexplained 30%

Ovulatory 27%

Male factor 19%

Tubal 14%

Endometriosis 5%

Other factors 5% (uterine, endometrial, gamete or embryo defect)

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5
Q

Indications for early referral (female)

A

Aged over 35 years

Amenorrhoea/ oligomenorrhoea

Previous abdominal/ pelvic surgery

Previous PID/ STD

Abnormal pelvic examination

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6
Q

Indications for early referral (male)

A

Previous genital pathology

Previous STD

Significant systemic illness

Abnormal genital examination

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7
Q

Abnormal semen analysis

A

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

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8
Q

Female age

A

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

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9
Q

Female assessment

A

Screen for chlamydia and rubella

Ovarian reserve

  • early follicular hormone level
  • AMH
  • AFC

Ovulation test

Tubal test

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10
Q

AMH (anti- mullarian hormone)

A

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

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11
Q

Ovulation

A

Most women who have a regular menstrual cycle will be ovulating

BBT, ovulation detection kits, cervical mucous pattern, follicular tracking or mid- luteal phase

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12
Q

Tubal patency

A

Disease can be proximal (25%) or distal (75%)

PID secondary to chlamydia is the commonest cause of tubal damage

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13
Q

Risk of tubal damage

A

12% after one episode of pelvic infection

23% after two episodes

54% after three episodes

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14
Q

Other causes of tubal patency

A

Septic abortion

Ruptured appendix

Pelvic surgery

Ectopic pregnancy

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15
Q

Hysterosalpingogram

A

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%

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16
Q

HSG advantages

A

Relative safety

Ease of use

Delineation of the uterine cavity and fallopian tubes

17
Q

HSG disadvantages

A

Inability to assess the pelvic peritoneum

18
Q

Hysterosalpingo-contrast-ultrasonography

A

Similar to HSG

No radiation so relatively safer

Ovarian and uterine assessment is possible

Time consuming and requires training

19
Q

Laparoscopy and dye

A

Invasive procedure with inherent risks of visceral injury to the patient

More sensitive and specific

Chance to diagnose and treat endometriosis and adhesions

20
Q

Uterine abnormality

A

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

21
Q

Ovulation induction

A

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

22
Q

IUI treatment usual indications

A

Unexplained

Mild male factor

Mild endometriosis

23
Q

IUI treatment

A

Less stress

Less invasive

Less tech

Cheap

24
Q

NICE guidelines

A

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

25
Q

IVF for

A

Tubal damage

Low sperm

Unexplained infertility

Low ovarian reserve

26
Q

IVF LBR

A

Depends on female partner’s age

Varies from one unit to another

National average 30-35% <35 year old