Fertility Flashcards
What is the distinction between primary and secondary infertility?
PRIMARY = when neither partner has ever conceived
SECONDARY = when one or both partners have conceived before (either together or with a different partner
On average, how many couples will conceive after 12-24 months of unprotected intercourse?
-85% within 12 months
-92% within 24 months
-Infertility = failure to conceive after 12 months of regular unprotected sex
What are the 3 main requirements for conception?
-Ovulation
-Tubal patency
-Healthy sperm
What are the common causes of infertility?
-Sperm problems (30%)
-Ovulation problems (25%)
-Tubal problems (15%)
-Uterine problems (10%) eg bicornate uterus, polyps, adhesions
-Unexplained (20%)
NB 40% of couples will have mixed male and female causes
What are the different possible types of sperm problems that can cause infertility?
-Azoospermia = absent spermatozoa
-Oligospermia = few spermatozoa
-Teratozoospermia = excess numbers of abnormal sperm
-Asthenzoospermia = large proportion of immotile sperm
-Can be caused by trauma, previous chemotherapy, anabolic steroid use, CF, hypogonadism, but commonly idiopathic
How can male factor infertility be managed?
-Sperm ejaculate sample (if abnormal, repeat in 3 months)
-If sperm present in sample:
–ICSI = inject sperm directly into egg
-If sperm not present in sample:
–Surgical sperm retrieval / PSA = sperm collected from epididymis, blockage along vas deferens
–Surgical correction = resolving blockage in vas deferens
–Intra-uterine / donor sperm insemmination = injection into uterus
What are the three main causes of anovulatory infertility?
Group I - hypothalamic / pituitary failure
Group II - PCOS (90%)
Group III - premature ovarian insufficiency
What are some causes of hypothalamic / pituitary failure infertility?
-Weight loss / systemic illness
-Anorexia nervosa
-Pituitary surgery or irradiation
-Inflammatory causes eg TB, sarcoidosis
-Sheehan’s (postpartum pituitary necrosis)
-Congenital eg Kallmann’s syndrome
-Hyperprolactinaemia
What changes to hormone levels would you expect in hypothalamic / pituitary failure?
FSH - very low
LH - very low
E2 - very low
leads to peri-menopausal symptoms
How can you manage hypothalamic / pituitary failure infertility?
-Correct weight / underlying health problems
-Discourage extreme exercise
-Gonadotrophins to induce induction once a healthy weight etc
How does PCOS cause anovulatory infertility?
-Increased GnRH –> increased LH –> increased theca cell testosterone secretion
-Reduced sex hormone-binding globulin levels
-Arrest in folliculogenesis and ovulation
What changes to hormone levels would would expect in PCOS?
FSH - low/normal
LH - high / normal
E2 - high / normal
What is premature ovarian insufficiency and how is it diagnosed?
-Loss of ovarian activity before the age of 40
-Oligo/amenorrhoea for at lest 4 months
-Elevated FSH (>25) on two occasions >4 weeks apart (measured on day 1-3 of menstrual cycle)
What changes to hormone levels would you expect to see in POI?
FSH - very high
LH - high
E2 - high
What can cause POI and how can it be managed?
-Turner’s syndrome (45X)
-Fragile X synrome
-Addison’s disease, thyroid pathology
-Hyperprolactinaemia
MANAGEMENT
-Egg donation
-HRT (E2 and P4)
What investigations can be done to assess tubal patency?
-Hysterosalpingogram
-Laparoscopy and dye test
What can cause tubal factor infertility and how can it be managed?
CAUSES
-PID
-Untreated STIs
-Endometriosis
-Adhesions
MANAGEMENT
-Tubal cannulation (during hysterosalpingogram)
-Lapasocopic removal of adhesions or endometriosis
-IVF
When is the ‘fertile window’?
-Egg is viable for 24h after ovulation
-Sperm are viable in uterus for 5 days
-Ovulation normally occurs on day 14-16 of 28-day cycle
-So fertile window = day 9-17
What pre-conceptual advice can be given to couples?
BOTH
-Stop smoking
-Little / no alcohol
-Optimise BMI
-Stop recreational drug use, avoid occupational hazards, STI screen
WOMEN
-Up to date smear
-?Reduce caffeine intake?
-Take folic acid and vitamin D supplements
MEN
-Avoid elevated scrotal temperature
In summary, what investigations should be done for a couple presenting with infertility?
-HPO axis assessment (FSH, LH, oestrogen, testosterone, progestogen, prolactin)
-Semen analysis (count >15 million/ml, motility >40%, normal formation >4%)
-Assess anatomy (USS)
-Assess tubal patency
What are the different assisted reproduction options?
IUI = insertion of selected seminal fluid into uterus around time of ovulation
–Ideal for asthenzoospermia
ICSI = single sperm injected directly into single egg
–Ideal for oligospermia
IVF = egg and sperm are fertilised lab and embryo is then implanted into uterus
What is the best way to test for ovulation?
-Day 21 progesterone level
What causes OHSS and what are its symptoms?
-Increase in vascular endothelial growth factor release from granulose cells of follicles
-Increased vascular permeability –> fluid leakage
-LH/FSH therapy for ovarian stimulation requires hCG injection 36h before oocyte collection –> triggers OHSS
SYMPTOMS
-Oedema
-Ascites
-Abdo pain, N+V
-Hypovolaemia / hypotension
-Associated with raised renin level due to activation of the RAS
Who is most at risk of OHSS?
-Younger age
-Low BMI
-Raised AMH
-High follicle count
-PCOS
-Raised oestrogen levels during ovarian stimulation
