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
Physical examination for females
General Inspection:
- Hirsutism/Acne: increase testosterone (PCOS)
- Thyroid masses
- Galactorrhoea: hyperprolactinemia
- BMI: Obesity (increases health risk)
- Signs of Turner’s Syndrome
Abdominal Examination:
- Masses: adnexal masses/cysts/fibroids
- Scars from past surgeries
Speculum Examination:
- HPV/Pap smear
- Chlamydia Gonorrhoea swab
Vaginal Examination:
- Fixed retroverted uterus, adnexal masses, uterosacral nodules: Endometriosis, endometrial cysts/fibroids
- Adnexal masses, cervical excitation: PID
Per rectal examination if suspect endometriosis
How can endometriosis cause infertility?
- Adhesions -> impair tubal structure
- Excessive release of prostaglandins, cytokines and chemokines -> chronic inflammatory state
=> affects folliculogenesis, ooctye quality, fertilisation, implantation
PID is strongly associated with what infection?
Chlamydia infection
When is amenorrhea panel generally done for screening?
Day 2-3 of menses - to attain basal FSH, E2 concentrations without significant variation
- High FSH: indication of reproductive aging, reduced ovarian reserve and reproductive potential
- High E2 (alw compare with FSH): advanced follicular development
- Indication of any hypothalamus-pit-ovary issues
Expected normal findings of XRAY in hysterosalpinography
Flow of dye through bilateral patent tubes
Triangular configuration of uterus
Spillage of constrast into peritoneal cavity
What is all investigations return as normal?
Dx of exclusion: Unexplained infertility
Complications of IVF
Bleeding, infection, injury to surrounding organ
Multiple pregnancy
Ovarian hyperstimulation syndrome
Failure of procedure
Ectopic pregnancy
Most common aetiology for tubal block
PID
