Fertility Flashcards
How do you confirm ovulation?
Take the serum progesterone level 7 days prior to the expected next period
> 30 nmol/l indicates ovualtion
counselling points fertility
folic acid
aim for BMI 20-25
advise regular sexual intercourse every 2 to 3 days
smoking/drinking advice
Basic fertility investigations
semen analysis
serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21.
When do you initiate investigations for infertility
After 12 months of trying
After 6 months if >35
Advice for couples trying to conceive
The woman should be taking 400mcg folic acid daily
Aim for a healthy BMI
Avoid smoking and drinking excessive alcohol
Reduce stress as this may negatively affect libido and the relationship
Aim for intercourse every 2 – 3 days
Avoid timing intercourse
Initial investigations infertility
BMI
chlamydia screening
Semen analysis
Female hormone testing: FSH, LH, Progesterone, AMH, prolactin
Rubella immunity testing
When is LH and FSH tested - fertility
day 2 to 5 of the cycle
When is progesterone measured - fertility
7 days before end of cycle
What does FSH indicate - fertility
High FSH suggests poor ovarian reserve (the number of follicles that the woman has left in her ovaries). The pituitary gland is producing extra FSH in an attempt to stimulate follicular development.
What does LH indicate- fertility?
high could indicate PCOS
what does progesterone indicate - fertility
A rise in progesterone on day 21 indicates that ovulation has occurred, and the corpus luteum has formed and started secreting progesterone.
What does AMH indicate- fertility
It is released by the granulosa cells in the follicles and falls as the eggs are depleted. A high level indicates a good ovarian reserve.
Secondary care investigations
Ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus
Hysterosalpingogram to look at the patency of the fallopian tubes
Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis
Management of anovulation
Weight loss for overweight patients with PCOS can restore ovulation
Clomifene may be used to stimulate ovulation
Letrozole may be used instead of clomifene to stimulate ovulation (aromatase inhibitor with anti-oestrogen effects)
Gonadotropins may be used to stimulate ovulation in women resistant to clomifene
Ovarian drilling may be used in polycystic ovarian syndrome
Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)
How does clomifene work
Clomifene is an anti-oestrogen (a selective oestrogen receptor modulator). It is given on days 2 to 6 of the menstrual cycle. It stops the negative feedback of oestrogen on the hypothalamus, resulting in a greater release of GnRH and subsequently FSH and LH.
Define oligospermia
Mild oligospermia (10 to 15 million / ml)
Moderate oligospermia (5 to 10 million / ml)
Severe oligospermia (less than 5 million / ml)
Instructions for providing a sperm sample
Abstain from ejaculation for at least 3 days and at most 7 days
Avoid hot baths, sauna and tight underwear during the lead up to providing a sample
Attempt to catch the full sample
Deliver the sample to the lab within 1 hour of ejaculation
Keep the sample warm (e.g. in underwear) before delivery
Pre-testicular causes of male factor infertility
Testosterone is necessary for sperm creation. The hypothalamo-pituitary-gonadal axis controls testosterone. Hypogonadotrophic hypogonadism (low LH and FSH resulting in low testosterone), can be due to:
Pathology of the pituitary gland or hypothalamus
Suppression due to stress, chronic conditions or hyperprolactinaemia
Kallman syndrome
Testicular causes of male factor infertility
Testicular damage from:
Mumps
Undescended testes
Trauma
Radiotherapy
Chemotherapy
Cancer
Genetic or congenital disorders that result in defective or absent sperm production, such as:
Klinefelter syndrome
Y chromosome deletions
Sertoli cell-only syndrome
Anorchia (absent testes)
Post testicular causes of male factor infertility
Obstruction preventing sperm being ejaculated can be caused by:
Damage to the testicle or vas deferens from trauma, surgery or cancer
Ejaculatory duct obstruction
Retrograde ejaculation
Scarring from epididymitis, for example, caused by chlamydia
Absence of the vas deferens (may be associated with cystic fibrosis)
Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)
Further investigations after abnormal semen sample identified
Hormonal analysis with LH, FSH and testosterone levels
Genetic testing
Further imaging, such as transrectal ultrasound or MRI
Vasography, which involves injecting contrast into the vas deferens and performing xray to assess for obstruction
Testicular biopsy
success rate of IVF
Each attempt has a roughly 25 – 30% success rate at producing a live birth
complications IVF
Failure
Multiple pregnancy
Ectopic pregnancy
Ovarian hyperstimulation syndrome
Basic IVF process
- supression of menstrua cycle with GnRH agonists or antagonists
- ovarian stimulation with FSH
- hCG trigger injection
- oocyte collection
- oocyte insemination
- culture
- transfer
- pregnancy test after 26 days
Pathophysiology of ovarian hyperstimulation syndrome
bHCG injections –> stimulation of granulosa cells –> increase in vascular endothelial growth factor (VEGF) –> increased vascualr permeability –> oedema/ascites/hypovolemia
also renin high due to RAAS activation
what indicates higher risk for OHSS
Serum oestrogen levels (higher levels indicate a higher risk)
Ultrasound monitor of the follicles (higher number and larger size indicate a higher risk)
Features OHSS
Abdominal pain and bloating
Nausea and vomiting
Diarrhoea
Hypotension
Hypovolaemia
Ascites
Pleural effusions
Renal failure
Peritonitis from rupturing follicles releasing blood
Prothrombotic state (risk of DVT and PE)
Management OHSS
Oral fluids
Monitoring of urine output
Low molecular weight heparin (to prevent thromboembolism)
Ascitic fluid removal (paracentesis) if required
IV colloids (e.g. human albumin solution)
What blood test may be useful in monitoring the amount of fluid in intravascualr space - OHSS
Haematocrit may be monitored to assess the volume of fluid in the intravascular space. Haematocrit is the concentration of red blood cells in the blood. When the haematocrit goes up, this indicates less fluid in the intravascular space, as the blood is becoming more concentrated. Raised haematocrit can indicate dehydration.
gold standard to check patency of tubes
laparoscopy and dye
