Female fertility Flashcards
Definition of infertility
Inability to conceive after 12 months of unprotected regular sexual intercourse (2-3x/week)
*6 months if 35 yo and above
- Primary infertility: No prior pregnancy
- Secondary infertility: Occurs after a previous conception
Main causes of infertility
- Ovulatory dysfunction
- Tubal factor
- Male factor
Causes of female infertility
- Ovulation
- Hypothalamic-pit causes
- PCOS
- Premature ovarian insufficiency
- Low ovarian reserve - Tubal block
- Past surgery -> adhesions
- Ectopic pregnancies/salpingectomies
- Endometriosis
- Pelvic inflammatory disease (*strongly a/w chlamydia)
- Tubal ligation - Uterine
- Endometrial polyps/cysts
- Submucosal fibroids
- Ashermann’s syndrome
- Uterine abnormality eg. bicornuate uterus, septated uterus - Cervical
- Anatomical defects
- Poor cervical mucus - Endocrine disorders
- hyperprolactinemia
- PCOS
- hyperandrogenism
- hypothyroidism
General investigations for female infertility
Ensure no other existing problems
1. Preconception screening
- FBC, thalassemia
- Hep B, HIV, syphillis
- Rubella and varicella IgG
- Blood group
2. HPV/Pap smear
3. Chlamydia/Gonorrhea
Fertility investigations for female infertility
Bloods
- Anti-mullerian hormone: ovarian reserve
- Mid luteal phase progesterone (check D21, 7 days before predicted menses)
- TFT
- Amenorrhea panel (testosterone, E2, FSH, LH, prolactin): PCOS, premature ovarian failure, hypothal-pit
Imaging
- U/S pelvis: submucosal fibroids, polyps, cysts, endometriosis, hydrosalpinx
- Hysterosalpingogram: tubal occlusion
General advice given for female fertility
- Folic acid supplementation
- Exercise
- BMI < 30 (can affect fertility)
- Smoking cessation
- Limit 1-2 units of alcohol per week
Management options for woman infertility and their indications
- Timing of ovulation with or without ovulation induction
- Ovulatory dysfunction: PCOS, irregular cycles
- Unexplained infertility - Intrauterine insemination with or without ovulation induction
- Mild male factor
- Ejaculatory failure
- Hypogonadotropic hypogonadism
- Vaginal acidity
- Cervical mucus hostility - In-vitro fertilisation
- Tubal disease
- Age
- Low ovarian reserve
- Moderate-severe male factor - If uterine factor -> hysteroscopic resection
Ovulation induction agents
1st line: Clomiphene citrate
*anti-estrogen
*works at pit level to increase FSH pdtn -> promote follicular devt
- Letrozole
- Gonadotropin
- Bromocriptine, cabergoline (for hyperprolactinemia)
- Metformin
Timing of ovulation
Give ovulation induction agents if anovulatory: D2-D5 of menses
Attend ultrasound scans to track ovarian follicle growth on D12 of menses cycle
- Once follicles reaches 17-18mm = fertile period
- Advice for sexual intercourse
Intrauterine insemination
A procedure in which a washed ejaculated semen specimen is injected directly into uterus using a fine catheter passed through the cervical canal and timed to take place just prior to ovulation
Procedure for IUI
- Give ovulation induction agents if anovulatory: D2-D5 of menses or not necessary in a woman who ovulates regularly
- Attend ultrasound scans to track ovarian follicle growth on D12 of menses cycle
- Once follicles reaches 17-18mm = fertile period - Once follicle reaches 17-18mm, give HCG injection (mimic LH surge) to trigger maturation and release of oocyte 36h later
- Detection of urine or serum LH and U/S confirmation of follicle rupture -> ensure ovulation occurs before insemination
- Semen collection and preparation
- Return 36h later for intrauterine insemination of sperm into uterine cavity (clinic procedure)
- expose cervix with speculum and clean
- prepared sperm is drawn into tuberculin syringe and attached to IUI catheter
- catheter inserted into uterine cavity and semen is injected
Sperm preparation
Fresh sperm is collected via masturbation
Preparation methods include:
- Conventional swim up procedure
- Sperm washing
- Using a density gradient technique
Complications of IUI
- Uterine contractions and discomfort
- Intrauterine infections
In-vitro fertilisation
- Prevent ovulation: Pituitary down regulation (GnRH agonist/antagonist)
- Take over ovulation: Controlled ovarian stimulation (Urinary gonadotropin injections)
- Oocyte retrieval (under GA)
- Sperm recovery (masturbation)
- Fertilisation
- Embryo replacement (in OT)
- only 2 embryos allowed at any one time
Pertinent fertility-specific hx taking points for females
- Establish Diagnosis
- How long have they been trying to conceive (1 year? 6 months if 35 years and above)
- Issues/difficulties with sexual intercourse (sexual dysfunction?)
- How often is sexual intercourse (2-3 times a week) - Previous fertility treatments
Female
3. Gynae code: Age**/years married/miscarriages or abortions/parity or children
4. Contraceptions use (depo provera -> delay in return to fertility)
5. Drug use and compliance (drugs causing hyperprolactinemia)
6. Drug allergies
7. Occupation
8. Smoking/Drinking
- Past medical and surgical history
- Ruptured appendicitis, bowel surgery
- Gynaecological surgery: endometriosis, cystectomies/oophorectomies, ectopic pregnancies
- Pelvic inflammatory disease
- Safety for pregnancy: DM/HTN etc - Menstrual History (LMP)
- Regular/irregular/amenorrhoea (ovulatory)
- Menorrhagia (Submucosal fibroids, adenomyosis)
- Intermenstrual bleeding (polyps)
- Dysmenorrhoea (endometriosis), dyschezia - Endocrine disorder symptoms
- Gynae screening: pap smear/HPV up to date, past results
- Family history of genetic disorders
