Fertility Flashcards
Definition and incidence of azoospermia
Complete absence of spermatozoa in the ejaculate
1% all men, 10-15% infertile men
Obstructive causes of azoospermia
MC in the vas deferens epididymus or ejaculatory ducts
- infections
- inflammation
- prev surgery in pelvic area
- development of a cyst
- hernia surgery
- vasectomy
- cystic fibrosis
Non-obstructive causes of azoospermia
Genetic: Kallmans, Klinefelter, Y chromosome deletion
Hormone imbalances
Retrograde ejaculation
Testicular causes:
- Anorchia
- cryptorchidism
- sertoli cell-only syndrome
- Spermatogenic arrest
- mumps orchitis
- testicular torsion
- tumours
- reaction to meds
- radiation
- chronic disease - DM, cirrhosis, renal failure
- Varicocoele
Diagnosing azoospermia
2 separate samples, examined under high-powered microscope following centrifuge spin
If first sample shows azoospermia, send repeat sample ASAP
NB history points wrt azoospermia
Fertility success/ failure
Childhood illness
Surgery/ trauma to pelvic area
Urinary/ reproductive duct tract infections
STIs
Exposure to chemo/ radio
Current/ past meds
Alcohol/ smoking/ drug use
Recent fever or exposure to heat
FHx birth defects, learning disabilities, repro failure or CF
Pituitary sx - anosmia, visual field defects, loss of libido
Ix in azoospermia
Testosterone and FSH level
Genetic testing
XR/ USS reproductive organs
Brain imaging (MRI pituitary)
Testicular biopsy
Management of azoospermi
Depends on cause
Blockage - surgery - unblock/ reconstruct
Low hormone production - HRT: FSH, HCG, clomiphene, anastrazole, letrozole
Varicocoele - surgery
Extensive biopsy for direct sperm retrieval
Abnormal types of findings on semen analysis
Asthenozoospermia - reduced mobility
Oligozoospermia - sperm concentration < 20x10^6/ml
Teratozoospermia - abnormal morphology
Hypospermia - decreased volume ejaculate
Azoospermia - no sperm in sample
Values looked at in semen analysis
Sperm volume
Sperm concentration
Total sperm count
Sperm progressive motility
Sperm morphology
SpermDNA fragmentation
Non-sperm cells
Normal cut off value for sperm volume and concentration
Volume - >1.5ml
Concentration - > 15 million/ml
Normal total sperm count
> 39 million
Normal sperm morphology and motility
Morphology > 4%
Motility > 32%
When to perform an HSG
within first 10 days of a cycle
CI to HSG
Pregnancy
Pelvic infection
Findings seen on HSG
Tubal blockage
Obstruction site
Lumen on tube
Presence of adhesions
Orientation of tubes
Hydrosalpinx
Uterine anomalies
TL reversal
What is salpingitis isthmica nodosa
AKA SIN, diverticulosis of fallopian tubes
= consequence of prev PID
- multiple small diverticular collections of contrast around tube
DDX salpingitis isthmica nodosa
Tubal TB
Endometriosis
Tubal adenomyosis
Risks assoc w HSG
Infection
Injury
Allergy to dye
Radiation exposure
Side effects of HSG
Cramps
Dizziness
Nausea
Vaginal bleeding 1-2days
Problems with fertility in Turners syndrome
Common due to rapid loss of eggs in ovaries
Spontaneous pregnancy is rare - 8%
High rate of miscarriage - 40-45%
Can fall pregnant with donor eggs but increased risk
What makes Turners patients’ pregnancies high risk
Developing heart vessel problems
- during pregnancy, can have aortic rupture
- 100x more likely to die during pregnancy
- vessel changes can persist post pregnancy leading to early. death in mother
NB to have cardio consult and MDT input
40-60% risk of CS due to short stature
Contraindications to pregnancy in Turners patient
Aortic diameter > 35mm
Hx of aortic surgery
Uncontrolled HTN
Impacts of smoking on reproductive health
Cigarette metabolites are toxic to gametes
- morphological problems with sperm
- oxidative damage at oocyte and embryo
Brings forward the age of menopause
Higher change of LBW, PTB, IUGR, SIDS
- LBW: 200% inc risk
- PTB: 50%
- miscarriage: 20-30% risk T1miscarriage
IVF - 40% less likely to conceive if ongoing smoking
Defn POI/ POF
Menopause <40
Approx 1% women
0.1% <30
0.01% <20
Modifiable risk factors for POF
Smoking
Chronic disease treatment
Causes of POF
90% no underlying cause found; spontanous/ idiopathic
Autoimmune (5%)
- 12OH-Ab or ACA (adrenocortical antibiodies), addisons –> refer endo
- TPO Ab; TSH measured yearly
Genetic: Turners, Fragile X, Galactossaemia
Fam Hx
Infections: mumps, TB, malaria
Surgery
Cancer rx
Investigations for POF
Genetic/ chromosomal:
- karyotyping –> ? Turners –> +ve: refer endo, cardio and genetics
- Test for Y chromosome material –> discuss gonadectomy
- Fra-X –> refer genetics
- Autosomal Ab testing if evidence suggesting specific mutation eg BPES
Antibodies:
- ACA/ 12OH Ab –> refer endo
TPO-Ab –> TSH testing yearly
Signs of POF
Anxiety
Changes in mood
Chhanges in skin conditions
Difficultysleeping
Discomfort during intercourse
Feelings of loss of self
Hair loss of thinning
headaches or migraines
Hot flushes
Increase in facial hair
Joint stiffness
L/o self confidence
Night sweats
Palpitations
Problems w memory/. brain fog
Tinnitus
L/olibido
Recurrent UTIs
Vaginal dryness
Diagnosing POF
Amenorrhoea and symptomatic
GDG recommends: Oligo/amenorrhoea for 4/12 and FSH >25 on 2 or more occasions 4 weeks apart
Managing bone health in POF
Lifestyle - weight-bearing exercise, weight, diet, smoking
E replacement - reduces fractures
Bisphosphonates
COCP
DEXA - if osteo, repeat in 5 years after E
Counselling in POF
Reduced life expectancy if untreated - CVS risks
Small chance of conception
Still use contraception if want to avoid pregnancy
Therapy
HRT in POF
No increase in breast Ca
P for uterine protection
- ethinylestradiol + oral cyclic progesterone
Annual monitoring
Androgens - evaluated 3-6 monthly, limited to 24 months
BRCA gene - HRT conrtaindicated in BRCA survivors, carriers w BSO can have HRT
Migraines and HTN should not be a contraindication
Definition of OHSS
Ovarian hyperstimulation syndrome
Complication of ART
- exposure to HCG, LH following controlled ovarian stimulation by FSH
- Production of proinflammatory markers - VEGF
- Increase vascular permeability
- loss of fluid into 3rd space –> ascites, pleural and pericardial effusions
- severe –> hypovolaemia, reduced serum osmolality and reduced sodium
Diagnosing OHSS
Abdo distension and pain following trigger injection to promote final follicular maturation
Early OHSS: within 7 days of injection; excessive ovarian response
Late OHSS: >10 days post HCG injection
Symptoms: severe pain, pyrexia, peritonism
Bloods: elevated HCT, reduced osmolality, reduced sodium
DDx of OHSS
Pelvic infection
Abscess
Appendicitis
Ovarian torsion
Cyst rupture
Bowel perf
Symptoms of OHSS
Abdo bloating
Abdo pain
N&V
Breathlessness
Reduced urine output
Leg and vulval swelling
Assoc comorbs such as thrombosis
NB history points wrt OHSS
Time of onset of symptoms relative to trigger
Med used for trigger - hcg vs GnRH agonist
Number of follicles on final monitoring scan
Number of eggs collected
Were embryos replaced and how many
PCOS diagnosis
Defn mild OHSS
Abdo bloating
Mild abdo pain
Ovarian size < 8cm
Defn mod OHSS
Moderate abdo pain
Nausea +/- vomiting
Ultrasound evidence of ascites
Ovarian size 8-12 cm
Defn severe OHSS
Clinical ascites +/- hydrothorax
Oliguria <30ml/hr
Haematocrit >0.45
Hyponatraemia <135
Hypo-osmolality <282
Hyperkalaemia >5
Hypoproteinaemia <35
Ovarian size >12
Critical OHSS
Tense ascites/ large hydrothorax
Haematocrit >0.55
WCC > 25
Oliguria/ anuria
Thromboembolism
ARDS
Outpatient management OHSS
Counselling
Fluid in/out monitoring
No NSAIDS
If severe - LMWH
Paracentesis
Monitoring:
- review in 2-3 days
- baseline labs repeated if worsening
- haematocrit NB guide to the degree of intravascular depletion
Which patients with OHSS to admit
Severe pain
Unable to maintain fluid intake
Worsening OHSS
Unable to attend follow up
Increasing HCT
Critical OHSS
Inpatient management of OHSS
MDT if persistent haemoconcentration and dehydration
Critical –> ICU
Sx relief:
- analgesia (no NSAIDs)
- fluid replacement
- avoid diuretics
- ascites –> paracentesis
- Thrombosis –> LMWH, TEDS
Surgical management if torsion/ ectopic
If in pregnancy - incr risk of PET and PTL
