Fertility Flashcards
How many couples are subfertile?
1/6 couples
Definition and causes of infertility
No chance of conceiving: • Tubular blockage after PID • Premature ovarian failure • No sperm • Ovaries removed
Diagnosis of subfertility?
No conception after 12 months of unprotected intercourse
What is the chance of spontaneous conception each cycle?
20%
What investigations are done for subfertile couples?
- Is there an egg? (mid luteal phase around day 21 progesterone) LH and FSH peak 24hrs before ovulation. USS of follicle growth.
- Is there a sperm? (semen analysis)
- Can they meet? (tubal patency test)
Why might someone not ovulate? (classifications)
WHO I: Hypothalamus problem (FSH and oestrogen low) hypogonadotropic and hypo-oestrogenic anovulation
WHO II: normogonadotropic, normo-oestrogenic (PCOS)
WHO III: hypergonadotropic anovulation, FSH up, oestrogen low
Treatment of WHO I anovulation
Hypothalamus doesn’t work
Give pump of Gn-RH or give FSH/LH
Treatment of WHO II anovulation
Clomiphene anti-oestrogen, tricks pituitary into producing more FSH-> induces ovulation
Can supplement FSH/LH in cyclical way
Ovarian drilling
SE of FSH/LH supplementation in WHO II anovulation?
Multiple pregnancies (20%) Ovarian hyperstimulation syndrome
Treatment of WHO III anovulation
Ovaries have given up
No eggs to can offer donor oocytes
Can try IVF as maximum stimulation may work
Summarise the hypothalamopituitary axis for female sex hormones
Hypothalamus-> GnRH (pulsatile)
GnRH travels to pituitary
Pituitary-> LH +FSH
LH-> corpus luteum to produce progesterone & oestrogen, relax, inhibin
LH-> ovulation
FSH-> follicle development, oestrogen and inhibin
Role of relaxin
Inhibits contractions of uterine smooth muscle
In labour, dilates cervical canal
Role of inhibin
Inhibits FSH (and LH) production
Role of oestrogen
Promotes development of female reproductive structures, feminine secondary sex characteristics and breasts
Increases protein anabolism
Decreases blood cholesterol
Inhibits GnRH, FSH& LH
How do you treat hyperprolactinaemia?
Dopamine agonist
Bromocroptine, cabergoline
Stop antipsychotic treatment
What needs to be true for semen analysis to be normal
Need at least 15million spermatozoa per ml of semen to be normal.
Motility 40% or more, morphology normal in more than 4% of them.
Causes of poor sperm count
• Infection (mumps, STDs)
• Trauma (surgery for inguinal hernia? Testicular torsion? TURP?)
• Drugs (steroid use, cannabis, cocaine, sulfaslazine, TCAs)
• Radiotherapy
• Varicocele
• Congenital (undescended testes, CF)
Increased testicular temperature (eg lorry drivers)
Working w/heavy metals and solvents
How is tubal patency assessed?
- Chlamydia serology
- Contrast ultrasound (HyCoSy) (saline test from catheter inside uterus, then use radiolucent gel)
- Hysterosalpingogram (X-ray with dye)
- Diagnostic laparoscopy (methylene blue) Gold standare for diagnosis but operative risk. Can be therapeutic (adhesions, endometriosis, fibroid resection)
Differences between primary and secondary infertility
Primary infertility: Never conceived
Secondary infertility: Never given birth. Possible ectopic pregnancy, miscarriage.
Causes (%) of female infertility
Ovulatory disorder (PCOS) (40%) Tubal factor (40%) Unexplained (15%) Uterine factor (5%)
Define IUI
When is it used?
Intrauterine insemination
Can be used in mild sperm defect or unexplained infertility.
Can be used in same sex couples.
Semen specimen is centrifuged and washed. Brought together at the right time. Can be done by monitoring a natural cycle or in a stimulated cycle. Can enhance cycle with clomiphene.
What can be done to improve tubal patency
Tubal surgery for:
Adhesions (previous chlamydia)
Blocked/damaged fallopian tube or distorted by large fibroids.
Reversal of sterilisation
When is IVF used?
- Tubal blockage
- After unsuccessful OI or IUI
- Severe male factor
- After 3 yrs unexplained infertility
What are the added options for IVF?
• Operative sperm removal from testes-> intracytoplasmic sperm injection
• Egg donation (if no eggs at all)
• Surrogacy (absent uterus)
Also pre-implant genetic diagnosis
