Fertility and Infertility Flashcards
Background
Fertility is defined as the capacity to reproduce.
Infertility is the failure to conceive (regardless of cause) after 1 year of unprotected sex.
As women’s age increases infertility also increases.
Reproduction requirements:
1. Release of a normal pre-ovulatory oocyte.
2. Production of adequate sperm.
3. Normal transport of the gametes to the ampullary portion of the fallopian tube (where fertilization occurs).
4. Then transport of the cleaving embryo into the endometrial cavity for implantation and development.
Unknown cause = unexplained infertility or normal infertile couples (NICs) meaning all tests showed normal.
Other classes:
Primary — in couples who have never conceived.
Secondary — in couples who have conceived at least once before (same or different partner).
Subfertility - prolong duration of unwanted lack of conception
Risk factors for infertility
- Increasing age
- Smoking
- Stress
- STIs - Chlamydia, gonorrhoea - damage genital anatomy
- Obesity
- Low body weight 10% below causes menstrual irregularities
- Occupational risks
- Excessive alcohol consumption
- Use of certain prescription, OTC, and recreational drugs (Affect ovulatory and tubal function) - Women:
NSAID can inhibit ovulation, Chemo can induce ovarian failure, Metoclopramide, methyldopa, sertraline, fluoxetine, and antipsychotics - supress hypothalamic pituitary function and increase prolactin,
MEN drugs =
Sulfasalazine and antifungals - affect spermatogenesis
, certain antipsychotics antidepressants, and antihypertensive - retrograde ejaculation and orgasmic dysfunction, Long term opiate, 5a reductase i, Finasteride, Hormone treatment, recreational drugs
Factors of affecting fertility (specific to sex)
Female:
* Cervical: Stenosis or abnormalities of the mucus-sperm interaction.
* Uterine: Congenital or acquired defects; may affect endometrium or myometrium; may be associated with primary infertility or with pregnancy wastage and premature delivery
* Ovarian: Alteration in the frequency and duration of the menstrual cycle—Failure to ovulate most common problem
* Tubal: Abnormalities or damage to the fallopian tube; may be congenital or acquired.
* Peritoneal: Anatomic defects or physiologic dysfunctions (e.g., infection, adhesions, adnexal masses).
MALE:
* Pretesticular: Congenital or acquired diseases of the hypothalamus, pituitary, or peripheral organs that alter the HPA.
* Testicular: Genetic or nongenetic.
* Post-testicular: Congenital or acquired factors that disrupt normal transport of sperm through the ductal system.
More on CKS
Diagnosis/Assessment
Have to be trying for 1 year b4 tests
Both Genders:
Take full medical, sexual and social history.
- Length of time trying to conceive
- Freq. of sex
- Length of time stopped contra
- Freq./regularity of cycles
- Hx STIs
- Systemic diseases
- Timing and results of recent cervical smear test
- Symptoms indicating ovulatory, uterine, cervical, peritoneal disorder
- Hx that may show testicular failure or obstructive azoospermia (no sperm)
- Hx of infertility, surgeries
- RISK FACTORS
Physical exam.
- BMI
- Pelvic/vaginal/penis/testes exam
- Women look for hirsutism and acne, galactorrhoea and cysts
- Men look for gynecomastia, lumps, small, soft testes, or undescended testes
Lab exams: (PACK not CKS)
- Semen analysis (Volume, pH, Conc. , Motility, morphology, WBC, Sperm function test)
- Women - Mid luteal phase progesterone (blood test), serum gonadotrophins, TFTs, Prolactin measurement (if have ovulatory disorder, galactorrhoea, sus pituitary tumour), Screen for chlamydia
Treatment/Management
HAVE TO REFER 1st (refer flash card)
Based on Diagnosis, duration of infertility, women’s age. May use pharmacotherapy, surgical or both.
3 main types: (Eg below)
- Medical treatment = restore fertility,
- Surgical treatment =restore fertility,
- Assisted reproduction techniques
Management:
First provide couple advise to reduce the risk factors i.e. smoking cessation, lose weight, stop illicit drugs, stress management, men avoid tight underwear.
Pre conception advise to women:
- Folic acid dietary supplements 0.4mg/kg
- Rubella tests - offer vaccine if susceptible.
- Cervical cancer screen
Medicines
- Clomifene – Ovulation inductor
- Tamoxifen – ALT to clomifene
- GnRh and dopamine agonists – Ovulation inductor
- Gonadotrophins – Ovulation inductor in women, and can improve fertility in men (clomifene-resistant anovulatory infertility)
- Metformin – Mainly PCOS
Surgery
- Fallopian tube surgery - if blocked or scarred makes egg pass easier
- Tubal microsurgery women with mild tubal disease
- Laparoscopic - endometriosis, remove submucosal fibroids, if have PCOS and meds dont work (laparoscopic ovarian drill)
- epididymal blockage and surgery to retrieve sperm - epididymis is a coil-like structure in the testicles that helps store and transport sperm. if blocked = infertility
Assisted reproductive technologies :
* In vitro fertilisation (IVF).
* Gamete intra-fallopian transfer (GIFT).
* Zygote intra-fallopian transfer (ZIFT).
* Intracytoplasmic sperm injection (ICSI).
* Intrauterine insemination (IUI).
* Sperm, oocyte, or embryo cryopreservation.
Refer
Typically refer b4 starting treatment
Refer:
- <36 years if everything is normal and they tried for 1 year
Consider referral if any of:
Women -
- >36 (after 6 months trying)
- Amenorrhoea or oligomenorrhoea.
- Previous abdominal/pelvic surgery.
- Previous PID or STI.
- Abnormal pelvic examination.
- Known reason for infertility (Eg prior treatment for cancer).
Men-
- Previous genital pathology, urogenital surgery or STI.
- Varicocele.
- Significant systemic illness.
- Abnormal genital exam
- 2 abnormal semen exam results.
- Known reason for infertility
Ensure counsel b4 during and after interventions. Stress etc
Complications of treatment (EXTRA)
- Ovarian hyperstimulation syndrome-
Treatment: urgent advise from specialist. - Ectopic pregnancy
- Pelvic infection
- Multiple pregnancy
REFER TO CKS FOR MORE INFO
