Fertility Flashcards
What is Ovarian Hyperstimulation Syndrome
- Complication of infertility treatment that promote the development of eggs in the ovaries
- Due to multiple developing luteinised ovarian cysts.
- release of oestrogens, progresterones and VEGf
What are the features of ovarian hyperstimulation syndrome
Abdominal pain and bloating Nausea and vomiting Diarrhoea Hypotension Ascites Reduced urine output Prothrombotic state with risk of VTE
Whats the management of OHS
- Supportive and treating the complications (e.g. ascitic drainage and anticoagulation).
- They may require admission to ICU in severe / critical cases.
What is the normal amount of time to conceive
85% will conceive within a year of regular unprotected sex. 1 in 7 couples will struggle to conceive naturally.
when should you refer for infertility investigations
- 12 months of trying
- 6 months if the woman is >35
What are the causes of infertility
- Sperm problems (30%)
- Ovulation problems (25%)
- Tubal problems (15%)
- Uterine problems (10%)
- Unexplained (15%)
- 40% of infertile couples have a mix of male and female causes of infertility.
What general advice should you give regarding fertility
- 400mcg folic acid daily
- healthy BMI
- Avoid smoking and drinking excessive alcohol
- Have intercourse 2-3 times a week.
- “Timed intercourse” to coincide with ovulation is not necessary or recommended
What investigations should you complete when looking at fertility
- BMI
- Anti-Mullarian hormone can be measured at any time during the cycle
- Serum LH and FSH on Day 2-5
- Serum progesterone on Day 21
- Ultrasound pelvis
- Hysterosalpingogram
- Laparoscopy and dye test
- Semen analysis
What may an abnormal BMI indicate regarding fertility
- Low: anovulation
- High PCOS
What may an abnormal FSH/LH indicate regarding fertility
- High FSH suggests poor ovarian reserve
- high LH suggests PCOS / ovarian failure.
What may an abnormal serum progesterone indicate regarding fertility
A rise indicates that ovulation has occurred and the corpus luteum has formed and started secreting progesterone.
What may an abnormal anti-mullarian hormone indicate regarding fertility
- most accurate maker of ovarian reserve (the number of follicles that the woman has left in her ovaries)
- released by the granulosa cells in the follicles and falls as the eggs are used up.
- Low level indicates poor ovarian reserves
Why might you do an US pelvis for fertility
- look for structural abnormalities of the uterus
- look of PCOS
Why might you do an Hysterosalpingogram for fertility
check the patency of the fallopian tubes
Why might you do a Laparoscopy and dye test for fertility
look at the patency of the fallopian tubes, adhesions and endometriosis.
What is Hysterosalpingogram
- scan used to assess the shape of the uterus and the patency of the fallopian tubes
- Seems to have therapeutic benefit
- tubal cannulation under X-ray guidance during the procedure to open up the tubes.
How is a Hysterosalpingogram done
- small tube is inserted into the cervix
- contrast medium is injected through the tube and fills the uterine cavity and fallopian tubes
- X-ray images are taken giving an outline of the uterus and tubes.
- If the dye does not fill one of the tubes, then a tubal obstruction can be diagnosed
What are the risks of a Hysterosalpingogram
-infection: often antibiotics are given prophylactically for patients with dilated tubes or a history of pelvic infections. - Screening for chlamydia and gonorrhoea should be done before the procedure.
What is the Laparoscopy and dye test
- dye can be injected into the uterus and should be seen entering the fallopian tubes and spilling out at the ends of the tube when they are patent
- During laparoscopy the surgeon can also assess for endometriosis or pelvic adhesions and treat these.
How do you manage anovulation
- Ovarian drilling: PCOS
- Clomifene to stimulate ovulation.
- Letrozole can be used instead of clomifene to stimulate ovulation. It is also an anti-oestrogen (an aromatase inhibitor).
- Gonadotrophins
- Metformin
What is clomifene
- anti-oestrogen (a selective oestrogen receptor modulator).
- given day 2-6 of the cycle and stops the negative feedback of oestrogen on the hypothalamus, resulting in greater release of GnRH and subsequently FSH and LH.
- Stimulates ovulation
Why give metformin for anovulation
can be used when there is insulin insensitivity and obesity (usually associated with PCOS). It improves these conditions making normal ovulation more likely.
How do you manage tubal infertility
- Tubal cannulation during a hysterosalpingogram
- Laparoscopy to remove adhesions or endometriosis
- In Vitro Fertilisation
How do you manage infertility as a result of uterine abnormalaties
Surgery to correct polyps, adhesions or structural abnormalities.
How do you manage sperm infertility problems
- Surgical Sperm Retrieval.
- Intra-Uterine Insemination.
- Intracytoplasmic Sperm Injection (ICSI).
What is surgical sperm removal
- blockage somewhere along the vas deferens preventing sperm from reaching the ejaculated semen.
- A needle and syringe is used to collect sperm directly from the epididymis.
What is inta-uterine insemination
- This involves collecting and separating out high quality sperm, then injecting them directly into the uterus to give them the best chance of success.
- It is unclear whether this is any better than normal intercourse.
What is intracytoplasmic sperm injection (ICSI)
- Sperm are injected directly into the cytoplasm of an egg. - These fertilised eggs are then injected into the uterus of the woman.
- This is useful when there are significant motility and other issues with the sperm.
What is in vitro fertilisation
- This involves fertilising an egg in the lab, and then injecting these fertilised eggs into the uterus.
- There are many steps along the way and it is a complicated and expensive process.
- As a result funding criteria are very strict and vary between different areas and couples are limited to a set number of cycles.
- Each cycle has a roughly 30% success rate.
What are you looking at when conducting semen analysis
This tests the volume and quality of the semen and sperm.
What advice should you give men undergoing semen analysis
- Abstain from ejaculation 3-5 days
- Avoid hot baths / sauna / 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) prior to delivery.
What factors may affect the result of semen analysis
Both baths Tight underwear Smoking Alcohol Raised BMI Caffeine
What factors do they look at when analysing sperm
- Semen volume (more than 1.5ml)
- pH of semen (>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%)
- Percentage of normal sperm (more than 4%)
