Fertility Flashcards
Define infertility
Disease of the reproductive system
Failure to achieve clinical pregnancy within 12 months of unprotected sex
Define primary infertility
Woman unable to ever bear a child as unable to become pregnant or carry a pregnancy
- miscarriages, ectopic, abortions and stillborn
Define secondary infertility
Unable to bear/ability to carry a child following previous pregnancy/having ability to carry pregnancy to live birth before
How common is infertility?
1 in 6 couples in UK experience some form of it
What are the causes of infertility and how common are they?
- male factors (30%)
- unexplained fertility (25%)
- ovulatory disorders (20%)
- tubal damage (20%)
- uterine/peritoneal disorders (10%)
How do the testes develop?
On posterior wall
- descends through inguinal canal
- into anterior abdomen wall
- into scrotum
- carries vessels, lymphatic nerves, ducts
What are the testes composed of?
Semniferous tubules
interstitial tissue surrounding tunica albuginea
What is the tunica vaginalis?
Sides and anterior aspects of testes covered by closed sac of peritoneum
What is the epididymis?
SIngle, long coiled lying alongside testes
- efferent ductules (head)
- true epididymis (body/tail continuous with vas deferens)
What is the vas deferens?
Long muscular duct
Transport spermatozoa from tail of epididymis to ejaculatory duct in prostate
What does the spermatic cord contain?
Vas deferens testicular artery Genital branch of genitofemoral nerve Pampiniform plexus Lymphatic vessels Tunica Vaginalis
Where does the spermatic cord run?
Through inguinal canal
Surrounded by fascia
What is the main blood supply to the male reproductive system?
Abdominal artery branches forming gonadal testicular artery
What is the venous drainage of the right testicle?
IVC
What is the venous drainage of the left testicle?
Left renal vein
What is the pampiniform plexus?
Network of small veins found in human spermatic cord
- surrounds artery
- cold as exits scrotum receiving heat from artery as travels back to abdomen
What are the 3 phases of the ovarian cycle and how long are they?
Follicular Phase (1-10) Ovulatory Phase (11-14) Luteal Phase (15-18)
What happens during the follicular phase?
- 5-12 primordial follicles stimulated each month
- 1 grows and matures
- GnRH secreted from hypothalamus stimulating anterior pituitary to secrete LH and FSH
- stimulates follicles to grow
- mature follicle secretes oestrogen
- inhibits LH and FSH secretion by anterior pituitary (negative feedback)
- stimulates endometrium growth
What happens during the ovulatory phase?
Negative feedback temporary
- oestrogen stimulates HPA
- LH and FSH burst
- completion of meiosis I and onset of meiosis II in oocyte
What happens during the luteal phase?
Granulosa cells of mature follicle divide forming corpus luteum
- secretes progesterone and oestrogen
- prepares uterine endometrium for implantation
What are the 3 phases of the menstrual cycle and how long are they?
- menstrual phase (day 1-5)
- proliferative phase (6-14)
- secretory phase (15-28)
What happens in the menstrual phase?
Withdrawal of steroid support (oestrogen and progesterone) = endometrium collapse
- endometrium shed with blood from rupture arteries
- 50-150ml blood loss
What happens in the proliferative phase?
Oestrogen from mature follicle stimulates thickening of endometrium
- glands/spinal arteries form
- oestrogen causes progesterone receptor growth on endometrial cells
What happens in the secretory phase?
Progesterone from corpus luteum acts on endometrium = gland enlargement
- glands secrete mucus and glycogen in preparation for implantation of fertilised oocyte
- no fertilisation = corpus luteum degenerates = corpus albicans and progesterone levels fall
What is the general conception advice?
- intercourse throughout the cycle
- no smoking, alcohol
- reduce weight/stress/drugs
- take folic acid (400mg)
What is COCP?
Trans acid, combined oral contraceptive pill
What are LARCs?
Ling acting reversible contraceptives
What is Gn therapy?
Gonadotrophins
What are the types of ovulatory causes of infertility?
1) Hypopituitary failure (anorexia) - increase weight, decrease exercise, Pulsatile GnRH
2) Hypopituitary Dsyfunction (PCOS, hyperprolactinaemia) - bromocriptine as dopamine agonist which regulates prolactin levels)
3) Ovarian failure (persistent raised FSH) - donor eggs, alternative parenting
What is the diagnostic criteria for polycystic ovarian syndrome? (PCOS)
- clinical hyperandrogenaemia
- oligomenorrhoea
- polycystic ovaries on ultrasound
- menstrual disturbance, acne
- raised LH with normal FSH, raised testosterone
What is the first line management of polycystic ovarian syndrome?
Clomiphene or metformin
What is the second line management for polycystic ovarian syndrome?
- combined clomiphene and metformin, lacroscopic ovarian drilling and Gn theraphy
What is important to exclude when diagnosing polycystic ovarian syndrome?
Thyroid dysfunction
Congenital Adrenal Hyperplasia
Androgen secreting tumours
What is an example of an ovulatory cause of infertility?
PCOS
What are examples of tubal and uterine causes of infertility?
Pelvic Inflammatory Disease
Endometriosis
Fibroids
What is pelvic inflammatory disease?
Infection of female upper genital tract
What are the symptoms of pelvic inflammatory disease?
Asymptomatic
Pelvic gain, dyspareunia, fever
- investigate with FBC and raised ESR
What is dyspareunia?
Painful sexual intercourse
What causes pelvic inflammatory disease?
Bacteria and STIs
chlamydia and gonorrhoea
How is pelvic inflammatory disease managed?
Antibiotics, rest, abstinence
What is endometriosis?
Presence of tissue histologically like endometrium outside uterine cavity
What are the symptoms of endometriosis?
Pain
Dysmenorrhoea (painful menstruation)
Menorrhagia
Dyspareunia
How is endometriosis managed?
NSAIDs
COCOP
GnRH agonists
Surgery
What are fibroids?
Benign tumours of SM of myometrium (uterine leiomyoma)
- heavy, regular periods
How are fibroids treated?
COCP
LARCs
Surgical
What are the male factors of infertility?
Testicular (infection, cancer, surgical, congenital, trauma)
Azoospermia (absence of motile sperm)
Reversal of vasectomy
Ejaculatory problems (retrograde and premature)
Hypogonadism
What is advised when there is unexplained fertility?
Do not offer clomiphene as no increased chance of pregnancy/live birth
- continue having regular unprotected intercourse
- IV after 2 years
Which drugs for women lead to infertility?
- long term NSAID
- chemotherapy
- neuroleptics
- spironolactone
- Depo-Provera
What is Depo-Provera?
Type of birth control injection
Delays fertility by around 6-12 months until return
What drugs for men lead to infertility?
Anabolic steroids
Chemotherapy
What drugs for men and women lead to infertility?
marijuana
cocaine
What are the NCIE guidelines when referring to infertility services?
- initial assessment: enquire lifestyle/sexual history
- only earlier referral is woman over 36 and known clinical cause of infertility/predisposition
What primary care investigations are done for infertility?
Full sexual/contraception/fertility history PCOS screen FBC (fibroids) Vitamin D HbA1c Viral screen rubella, HIV, hepatitis
What secondary care investigations are done for infertility?
Assess ovulatory function (blood tests, ovarian reserve testing)
Assess tubal function
Assess uterine function (laparoscopy)
How is a PCOS screen done?
day 21 progesterone LH FSH Serum testosterone glucose
What is ovarian reserve testing?
how receptive ovaries are to Gn stimulation
How is IUI done?
Intrauterine Insemination
- sperm separated in lab
- remove slower speed sperm before partner is inseminated
- insemination day 12-16
- ultrasound if ovarian stimulating drugs used
Who is IUI offered to?
- people unable to have intercourse
- required specific consideration
- same sex relationships
When is IUI tried?
12 cycles before IVF
What are the methods of assisted contraception?
Intrauterine Insemination
In-vitro fertilisation
Intracytoplasmic Sperm Injection
Who is IVF offered to?
- women under 40 who have not conceived after 2 years of unprotected intercourse = 3 cycles
- women 40-42 if never had IVF/6 or more IUI cycles/no evidence of low ovarian reserve = 1 cycle
What is ovarian hyper stimulation syndrome?
Consequence of drugs used to stimulate ovarian function
What is intracytoplasmic sperm injection? (ICSI)
Single sperm injected directly into egg
Who is ICSI offered to?
Intracytoplasmic sperm injection
- severe deficits in semen quality
- azoospermia
- IVF failure
How is ICSI compared to IVF?
Improves fertilisation rates more
Pregnancy rate is not better
What are the long term safety issues related to assisted reproduction?
Ovarian induction and ovarian stimulation (no direct associations between treatment/invasive cancer)
IVF - small increased risk of borderline ovarian tumours
