Fertility and subfertility Flashcards
Define subfertility
Couple are subfertile if conception has not occurred after a year of regular unprotected intercourse
Prevalence of subfertility
15%
Define infertility
Inability to concieve
Difference between primary and secondary subfertility
Never conceived vs conceived even if miscarriage/termination
What are the 4 conditions required for pregnancy?
1) Egg must be produced
2) Adequate sperm release
3) Sperm must reach egg
4) Fertilized egg must implant
What are the contributors to sub-fertility and their %
Ovulatory problems 30% Male problems 25% Tubal problems 25% Coital problems 5% Cervical problems <5% Unexplained (implantation?) 30%
Why does fertility decline with age?
Reduced genetic quality of remaining oocytes
What is mittelschmertz
Vaginal spotting, discharge or pelvic pain around ovulation
Clinical evidence of preovulation
1) Elevated serum progesterone in mid luteal phase (7days before menses)
2) Over the counter urine predictor kits shows LH surge
Fun scientific evidence of preovulation
Cervical mucus- fernlike patterns formed on dry slide and spinnbarkeit strings upto 15cm.
body temp drops 0.2 rises 0.5 in luteal
Define Polycystic ovary
Multiple small follicles in an enlarged ovary with regular cycles
Diagnostic criteria for Polycystic ovarian syndrome
2/3 criteria
1) PCO on US
2) Irregular periods >35d/ 5 weeks or more apart
3) Hirsutism: clinical (acne/excess body hair) or biochemical (increased testosterone)
Presentation of PCOS
Oligo/amenorrhoea, hirsutism, acne, obesity, increased rates of miscarriage, subfertility
How would you investigate for PCOS
FSH, LH, testosterone, prolactin, TSH
Fasting lipids and glucose
TVS«
Differentials for Anovulation (5)
Hypothalamic disease- low FSH Ovarian failure- high FSH PCOS- normal FSH Prolactinoma- Thyroid problems
Complications of PCOS (3)
Type 2 diabetes in 50%
Gestational diabetes 30%
Endometrial cancer (unopposed oestrogen)
Treatment of PCOS symptoms
Cant treat subfertility Advice to reduce weight COCP but neet 3-4 bleeds to protect endometrium Anti-androgens used for hirsutism Cyproterone acetate/Spironolactone Metformin-insulin sensitizer Eflornithine- topical,
Hyperprolactinaemia can be caused by (4)
Pituitary adenomas/hyperplasia
PCOS
Hypothyroidism
Psychotropic drugs
How do you treat prolacinomas
Bromocriptime/cabergoline- dopamine agonists- restores ovulation because dopamine inhibits prolactin release
Surgery if fails
Firstline treatment of PCOS and induction of ovulation by _, which is a _.
Clomifene 6 months days 2-6 antioestrogen blocking receptors in the hypothalamus and pituitary
Secondline treatment for PCOS
Lifestyle and weight loss
Clomifene then…
1) Metformin-oral insulin sensitizing restores ovulation
2)Gonadotrophins- daily subcut recombinant urine purified FSH+/-LH with LH surge/bhCG after a 17mm follicle develops. Give if weight normal.
3) Laproscopic ovarian diathermy- each ovary is monopolar diathermied at a few points for a few seconds + checked for all other pathologies
4)GnRH pump
5)IVF
Firstline ovulation treatment gives ovulation rate and live birth rates of
70% 40% (bad effect on endometrium)
How is follicular growth monitored after admin of all these therapies?
US
What are the side effects of ovulation induction
Multiple pregnancies
Ovarian hyperstimulation syndrome
Ovarian and breast carcinoma
What is OHSS?
Follicles get very large and painful.
Risk factors for OHSS
Gonadotrophin stimulation, age <35 years, previous OHSS and PCO
How do you cancel an IVF cycle?
Withold the hCG injection
Name the 4 terms that describe abnormal semen
Azoospermia, Oligospermia, Severe oligospermia, Asthenospermia
Whats Azoospermia and how do you examine further
No sperm present,
Examine the presence of vas deferens
Check karyotype, cystic fibrosis, hormone profile (FSH,LH, testosterone, prolactin, TSH)
Surgical sperm retrieval then IVF + ICSI or donor insemination
Whats Oligospermia/Severe
<5millon/mL- IVF +/- ICSI
Whats Asthenospermia
Absent/low motility sperm
How do you assess male fertility?
Semen analysis, repeated after 12 weeks if abnormal
Congenital absence of vas deferens and subsequent azoospermia is due to what genetic condition?
Cystic fibrosis
How do you manage male factor subfertility?
-General advice
-Specific measures eg subcut FSH/LH 6-12 months
-Assisted conception techniques-
IUI intrauterine insemination
ISCI-IVF intracytosplasmic sperm injection
SSR- Surgical sperm retrieval if azoospermia
DI- Donor insemination
What could the causes for lack of fertilization be?
Mostly tubal damage (25%)- PID (STIs, IUS,ruptured appendix)
Cervical problems
Sexual problems
What are the main causes of tubal damage?
PID-adhesions 12%
Endometriosis
Previous surgery/sterilization
What are the main treatments for tubal damage?
Adhesiolysis/salpingostomy
Lap surgery for endometriosis
IVF/Microsurgical tubal reanastomosis for ligated tubes
Cervical factors for subfertility are
Antibodies against sperm
Vagina/cervix infection which prevents mucus
Cone biopsy
How does one overcome cervical factors of infertility
By pass the cervix by IUI
How do you assess for tubal damage?
Hysteroscopy to check uterine cavity
Laparoscopy and dye test
HSG-hysterosalpingogram/TVS with HyCoSy
Name a few types of assisted conception
IUI- Interuterine insemination IVF +/- ISCI- in vitro fertilization, intracytoplasmic sperm injection FER- Frozen embryo replacement Oocyte donation PGD- Preimplantation genetic diagnosis
Indications for assisted conception
Unexplained subfertility, male factor subfertility, tubal blockage, endometriosis, genetic disorders, all else has failed
Whats stimulated IUI
gonadotrophin ovulation induction and then insemination
Ovarian failure makes which method of assisted conception impossible
IVF
How is ovarian reserve for IVF measured (2)
AMH-Anti mullerian hormone
TVS-AFC-Antral follicular count
What are the complications of assisted conception?
Superovulation-multiple pregnancies and OHSS
Egg collection causes intraperitoneal hemorrhage and pelvic infection
Pregnancy complications- ectopics/perinatal mortality/
How does fertility preservation measures differ in males and females in case of sterilizing disease/treatments?
Males can freeze samples, thawed and used during an IVF cycle.
Females have to freeze eggs (worse) or embryos. Male has right to withdraw consent even when woman then infertile.
