Fertility Flashcards
give 5 causes of infertility
- Failure of sperm problem (most common)
- Ovulation problem
- Tubal problems
- Uterine problems
- Unexplained
give 6 pieces of lifestyle advice for coupls getting pregnant
- 400mcg folic acid daily (woman)
- healthy BMI
- avoid smoking and excessive alcohol
- reduce stress
- aim for intercourse every 2-3
- AVOID timed intercourse
what female hormone testing is done for fertility investigations
- serum LH (high may = PCOS) on day 2-5
- serum FSH (high may suggest poor ovarian reserve) on day 2-5
- progesterone on day 21 : rise = ovulation has occurred
-anti-mullerian hormone : marker of ovarian reserve. high = good ovarian reserve - TFT
- Prolactin if Sx of galactorrhea or amenorrhea
what further Ix can be performed in secondary care to assess fertility
-USS pelvis for PCOS or uterine structural abnormalities
-Hysterosalpingogram to look at patency of fallopian tubes
-Laparoscopy and dye test for patency of fallopian tube, adhesions and endometriosis
what is a hysterosalpingogram
assess shape of uterus and patency of fallopian tubes
x-ray images are taken with a contrast medium
if dye doesn’t fill one of the tubes = obstruction
give 6 treatments options for anovulation
weight loss for PCOS
clomifene to stimulate ovulation
ovarian drilling in PCOS
metformin in insulin insensitivity & obesity
what is clomifene
-A selective oestrogen receptor modulator (anti-oestrogen)
Stops neg feedback of oestrogen on hypothalamus
Greater GnRH release and subsequently greater FSH and LH
how can sperm issues be managed
- surgical sperm retrieval if there is a blockage
- surgical correction of obstruction
- intra-uterine insemination
- intracytoplasmic sperim injection
- donor insemination
give 3 pre testicular causes of male infertility
- hypothalamus or pituitary pathology
- suppression due to stress, chronic conditions or hyperprolactinaemia
- kallman syndrome
can all cause hypogonadotrophic hypogonadism (low FSH, low LH = low testosterone)
Give 2 testicular causes of male infertility
- Testicular damage : Mumps, Undescended testes, Trauma, Radiotherapy, Chemotherapy, Cancer
- Genetic or congenital disorders : klinefelter, Y chromsome deletions, sertoli-cell only syndrome, anorchia (absent testes)
what are the post-testicular causes of male infertility
- ejaculatory duct obstruction
- rertrograde ejaculation
- scarring from epididymitis
- absence of vas deferens
give 5 Ix for male infertility
hormonal analysis : FSH, LH and testosterone
genetic testing
further imagining
vasography
testicular biopsy
what are the 6 steps of IVF
suppressing natural menstrual cycle
ovarian stimulation
oocyte collection
insemination
embryo culture
embryo transfer
how can the natural menstrual cycle be suppressed
-GnRH agonists (e.g. goserelin) : given in luteal phase. Itially stumulates pituitary to secrete large amounts of FSH and LH. There is then negative feedback suppressing natural GnRH, suppressing menstrual cycle.
-GnRH antagonist protocol (e.g. cetrorelix) : from 5-6 days of ovarian stimulation suppresses the body releasing LH and causing ovulation to occur
What Ix are performed in primary care for infertility ?
- BMI - > low could indicate anovulation, high could indicate PCOS
- Chlamydia screening
- Semen analysis
- Female hormonal testing
- Rubella immunity in the mother
what instructions are given to men prior to a semen sample and what is assessed in the 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
- Assess quantity and quality of semen and sperm
Normal sperm result s
- Semen volume (more than 1.5ml)
- Semen pH (greater than 7.2)
- Concentration of sperm (more than 15 million per ml)
- Total number of sperm (more than 39 million per sample)
- Motility of sperm (more than 40% of sperm are mobile)
- Vitality of sperm (more than 58% of sperm are active)
- Percentage of normal sperm (more than 4%)
Explain the difference between IVF and IUI
- In vitro fertilisation = fertilising egg with a sperm in the lab efore injecting embryo into uterus
- Intrauterine insemination = injecting sperm into uterus
how is ovarian stimulation done in IVF?
- Subcut injections of FSH from day 2 of cycle over 10-14 days
- When enough follicles have developed = injection of human chorionic gonadotropin hCG 36 hrs before egg collection
4 complications of IVF
Failure
Multiple pregnancy
Ectopic pregnancy
Ovarian hyperstimulation syndrome
How does OHSS present ?
- Early : within 7 days of hCG injection
- Late : from 10 days onwards
- Features : Abdominal pain and bloating, N&V, Diarrhoea
Hypotension, Hypovolaemia, Ascites, Pleural effusions, Renal failure, Peritonitis from rupturing follicles releasing blood, Prothrombotic state (risk of DVT and PE)
how is the severity of OHSS defined ?
- Mild: Abdominal pain and bloating
- Moderate: Nausea and vomiting with ascites seen on ultrasound
- Severe: Ascites, low urine output (oliguria), low serum albumin, high potassium and raised haematocrit (>45%)
- Critical: Tense ascites, no urine output (anuria), thromboembolism and acute respiratory distress syndrome (ARDS)
When would progesterone be taken to check for progesterone in a woman struggling with fertility ?
7 days before next expected period
Ovulation causes of infertility
- PCOS
- Hyperprolactinaemia
- Underweight
- Excessive exercise
- Premature ovarian insufficieny
Non patent fallopian tubes as cause of infertility
Endometriosis
Adhesions
Infection
If infertility is caused by hyperprolactinaemia, what other symptoms may be reported
Galactorrhoea
Menorrhagia
Bitemporal hemianopia
Diplopia
Management of hyperprolactinemia as a cause of infertility
Dopamine agonist (e.g. bromocriptine)
