Fertility Flashcards
What is the definition of subferitlity
Infertility
what is infertility
a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months (mark scheme also excepts 24 months) or more of regular unprotected sexual intercourse
what is primary infertility
When a woman is unable to ever bear a child, either due to the inability to become pregnant or the inability to carry a pregnancy to a live birth she would be classified as having primary infertility
What is secondary infertility
When a woman is unable to bear a child, either due to the inability to become pregnant or the inability to carry a pregnancy to a live birth following either a previous pregnancy or a previous ability to carry a pregnancy to a live birth
what are the causes of infertility
- Ovulatory disorders 25%
- Tubal damage 20%
- Uterine/peritoneal disorders 10%
- Male factors 30%
- Both male and female factors in 40% of cases where cause found
- Unexplained inferitility 25%
how can women work out there ovulating
LH test = LH peaks 36 hours before ovulation
temperature = increase in basal temperature rate
what are the general conception advice
- Intercourse throughout cycle
- Smoking
- Alcohol
- Folic acid 400mg, unless other problems than 5mg
- Weight
- Stress
- Caffeine – too much caffeine can cause stress levels to rise but no specific evidence
- Drugs – don’t like lansoprazole during pregnancy which is a PPI
- Occupation
what are the types of ovulatory causes of infertility
Type 1 - hypopituitary failure
type 2 - hypopituitary dysfunction
Type 3 - ovarian failure
describe examples of the different types of ovulatory causes of infertility
- Type 1 – hypopituitary failure – can be caused by anorexia nervosa
- Type 2 – hypopituitary dysfunction e.g. PCOS, hyperprolactinaemia
- Type 3 – ovarian failure (premature ovarian failure if under 40 years)
what is the difference between the polycystic ovaries and the actual symptoms
- need to have 2 out of 3 of the Rotterdam criteria to have PCOS
- a 1/3 of all women have polycystic ovaries
what is the Rotterdam criteria for PCOS
i)Clinical hyperandrogenaemia
ii) oligomenorrhoea (less than 6-9 menses per year)
Iii) 12 or more polycystic ovaries on ultrasound. Or ovaries greater than 10ml
what are the symptoms of PCOS
- irregular periods or periods that don’t work
- infertility hirsutism
- acne
- central obesity
- acanthuses nigricans
describe the hormones of PCOS
- Raised LH with normal FSH, Raised Testosterone (with or without reduced SHBG)
What does the raised testosterone in PCOS cause
- acne
- infertility hirsutism
what are the differential diagnosis to PCOS
- Exclude thyroid dysfunction, congenital adrenal hyperplasia, hyperprolactinaemia, androgen-secreting tumours.
what are people with PCOS at increased risk of
- If PCOS is confirmed they are at increased risk of altered lipid metabolism, and outside of pregnancy is to reduce weight is the best advice that can be given
List some tubal and uterine causes of infertility
- Pelvic inflammatory disease
- Previous tubular surgery including tubal surgery for ectopic pregnancy
- Endometriosis (tubal and uterine)
- Fibroids (uterine)
- Cervical mucus defect – some peoples cervical mucus is the wrong pH and this can kill the sperm
describe PID symptoms
- Asymptomatic
- pelvic pain
- deep dyspareunia
- malaise
- fever
- purulent vaginal discharge
describe the percentage cause of infertility and the increase in PID
More than 10% develop tubal infertility after 1 episode, 50% after 3 episodes
How do you treat PID
- antibiotics
- rest
- abstinence
what is the dentition of endometriosis
Presence of tissue histologically similar to endometrium outside the uterine cavity and myometrium
Most commonly found in the pelvis.
what are the symptoms of endometriosis
Pain, dysmenorrhoea, menorrhagia, dyspareunia
Ex: pelvic tenderness or mass, fixed uterus
describe the aetiology of endometriosis
- 1 in 5 women affected
- increased risk with age
- FH
- frequent cycles
How can you treat endometriosis
NSAIDs for pain, Norethisterone or COCP (4 packets run together),
Secondary Care-Danazol and GnRH agonists, Surgery.
What is another word for fibroids
uterine leiomyoma
- Benign tumours of the smooth muscle of the myometrium
who is fibroids common in
Approx 20% women (inc common in Afro-Carribean women)
what do people with fibroids complain of
Complain of heavy, regular periods
How do you treat fibroids
Tranexamic Acid, COCP/LARCs
Surgery
what is a difference between POCS and fibroids
PCOS is irregular periods where as fibroids is regular heavy periods
name and describe male causes of inferiority
Testicular (infection, cancer, surgical, congenital, undescended testes and trauma).
Azoospermia with or without sperm antibodies
Reversal of vasectomy – less common as LARCs used more frequently with women
Ejaculatory problems (retrograde and premature)
Hypogonadism
(Although not male infertility directly think about Erectile Dysfunction disorders: diabetes, depression and other psychological causes, stress is the most common cause and then we think about diabetes as well)
What are drugs for women that are linked to infertility
- Women long term NSAID use, chemotherapy, neuroleptics, spironolactone, depr-provera
- Marijuana, cocaine, other illicit drugs for both male and female
What are drugs for men linked to infertility
- Men- sulfasalazine, anabolic steroids, chemotherapy, chiense herbs for improving sperm count and motility
- Marijuana, cocaine, other illicit drugs for both male and female
describe the number of people who get pregnancy in the first year and then in the second year
80% couples pregnant after 12 cycles and 50% of the remainder conceive in the second year.
what are the NICE guidelines for referring someone with subfertility
“Offer an earlier referral for specialist consultation to discuss options for attempting conception, further assessment and appropriate treatment if:
- The woman in aged 36 years or over, and
- There is a known clinical cause of infertility or a history of predisposing factors for infertility
what do you screen both males and females for in primary care
Full Sexual/Contraception/Fertility History.
PCOS screen- day 21 progesterone, LH, FSH, serum testosterone, glucose
FBC (fibroids)
TFTs/TSH
Vitamin D
HbA1c (if any abnormality on glucose on PCOS screen)
Viral screen-Rubella, HIV, Hepatitis Screen
what does a semen analysis look for
WHO Ranges for Sperm Count:
• Volume (ml) Lower Range Limit 1.5ml
• Progressive Motility (%) Lower Range Limit 32%
• Morphology (%) Lower Range Limit 4% normal
how do you assess - ovarian function - tubal function - uterine function in secondary care
To assess ovulatory function:
• Bloods not done in primary care;
• Ovarian reserve testing-how female would respond to Gonadotrophin stimulation in IVF;
To assess tubal function: Hysterosalpingogram – this is when dye is injected in the room to look at the patency of the fallopian tubes – this can be painful
To assess uterine function: laparoscopy – for endometrioses to understand how significant things are
How do you treat type 1 hypopituitary failure as a cause of ovulatory infertility
- increase weight, decrease exercise.
* Consider pulsatile GnRH or Gn with LH activity to induce ovulation
How do you treat someone with PCOS who wants to get pregnancy
- Clomiphene
- weight loss of patient is overweight
surgery - ovary drilling
wedge resection
How do you treat someone with PCOS who does not want to get pregnant
- low dose contraceptive pills in order to restore menstrual regulatory
- metformin
- anti-androgens (e.g,cyproterone acetate)
how do you treat hyperprolactinaemia
Bromocriptine which is a dopamine agonist
how do you treat ovarian failure
consider donor eggs through assisted fertility, alternative parenting strategies.
HRT – protect bones and protect cardiovascular system, kept on HRT until reach menopause age of 51
what is the management of tubular problems causing infertility
Laproscopic tubal surgery-catheterisation/ cannulation
Surgery Prior to IVF attempt-fibroid/endometriosis clearance.
Adhesiolysis
Treatment of Endometriosis
what are the NICE guides for unexplained infertility
Do not offer clomiphene-no increased chance of pregnancy or live birth (NOTE INTERNET PURCHASES - watch out that they don’t do these).
To continue having regular unprotected intercourse for 2 years (investigations after 1 year).
Offer IVF after 2 years.
what happens in intrauterine insemination IUI
Sperm is separated in lab, removal of slower speed sperm, before partner is inseminated (partner or donor).
Who do you offer intrauterine insemination IUI to
- People who are unable to have vaginal intercourse (disability).
- Requiring specific consideration (eg sperm wash in HIV pos men)
- Same-sex relationships
How many cycles do you have of IUI before you offer IVF
12 cycles in total before offer IVF
what happens in IVF
Fertilisation of an egg (or eggs) outside the body then inseminated.
The treatment can be performed using own eggs and sperm, or using either donated sperm or donated eggs, or both.
who should you offer IVF to
- Offer 3 cycles to Women under 40 who have not conceived after 2 years of unprotected intercourse or 12 cycles of artificial insemination (6 IUI).
- Offer one cycle to 40-42 year old women if 2 years unprotected intercourse,12 cycles AI (6 or more IUI), never previously had IVF & no evidence of low ovarian reserve.
what are the predictors of successful outcome of IVF
Predictors of more successful outcome in IVF are Age, less cycles, previous pregnancies, BMI 19-30, no smoking, no ETOH, no caffeine.
what is ovarian hyperstimulation syndrome
Consequence of drugs used to stimulate ovarian function in IVF or PCOS
what are the symptoms of ovarian hyper stimulation syndrome
Mild: Lower abdo discomfort/distention, with or without nausea.
Severe: Abdo pain/distention, ascites, pleural effusion, venous thrombosis
how does intracytoplasmic sperm injection work (ICSI)
Embryologist selects a single sperm to be injected directly into an egg, instead of fertilisation taking place in a dish where many sperm are placed near an egg.
when do you offer intracytoplasmic sperm injection (ICSI)
- Severe deficits in semen quality
- Obstructive azoospermia
- Non-obstructive azoospermia
- Couple in whom previous IVF treatment cycle has resulted in failed or very poor fertilisation
- Appropriate investigations (eg semen analysis) for dx.
- Consider genetic issues (karyotype for Kallman’s) and microdeletions on Y-chromosome.
ICSI improves fertilisation rates …
• ICSI improves fertilisation rates compared to IVF alone, but once fertilisation taken place, the pregnancy rate is no better than with IVF
what are the safety risks with IVF
• Small increased risk of borderline ovarian tumours +/- ICSI
what do you do for people who wish to persevre fertility with cancer
Use sperm, embryos or ooctyes in cryopreservation.
Offer sperm cryopreservation in adolescent boys and men undergoing Ca treatment thought to render them infertile.
Offer oocyte/embryo cryopreservation to women of reproductive age if well enough to undergo ovarian stimulation and egg collection and enough time available before cancer Rx starts.
What are the 3 stages of the ovarian cycle
Follicular phase - day 1-10
Ovulatory phase - day 11-14
Luteal phase: day 15 - 28
describe the 3 stages of the ovarian cycle
Follicular phase: days 1 to 10
5-12 primordial follicles stimulated each month: one grows and matures.
GnRH secreted from hypothalamus: stimulates anterior pituitary to secrete LH and FSH.
o These stimulates follicle to grow.
Mature follicle secretes oestrogen.
o Inhibits further LH and FSH secretion by
anterior pituitary (negative feedback).
o Stimulates growth of endometrium.
Ovulatory phase: days 11 to 14
Negative feedback is temporary: oestrogen
stimulates HPA resulting in burst of LH and FSH.
o Completion of meiosis I, onset of meiosis II
in the oocyte.
Luteal phase: days 15 to 28
Granulosa cells of mature follicle divide and form
the corpus luteum
Secretes progesterone and oestrogen. Prepares uterine endometrium for implantation
what are the 3 stages of the menstrual cycle
Menstrual phase = day 1-5
Proliferative phase = day 6-14
Secretory phase = day 15-28
describe the 3 stages of the menstrual cycle
Menstrual phase (day 1-5): Due to withdrawal of steroid support (oestrogen/progesterone) the endometrium collapses. Endometrium is shed with blood from ruptured arteries (blood loss: 50-150ml).
Proliferative phase (day 6-14):
Oestrogen from mature follicle stimulates thickening of
the endometrium.
Glands/spinal arteries form.
Oestrogen also causes the growth of progesterone
receptors on endometrial cells.
Secretory phase (day 15-28):
Progesterone from corpus luteum: acts on endometrium.
Enlargement of glands secret mucus and glycogen in
preparation for implantation of fertilised oocyte.
No fertilisation = corpus luteum degenerates corpus
albicans. Progesterone levels fall.
