Fertility and Subfertility Flashcards
whats the definition of subfertility
inability to conceive after a year of unprotected intercourse
what is the prevalence of subfertility
15%
what are the 4 main ways in which fertility is affected and how do they affect
male factors (inadequate sperm release) - 25%
anovulation - 30%
malimplantation - 30%
sperm-egg not joining - 25% fallopian issue, 5% cervical issue, sexual issue 5%
%s add up to >100 because there is usually more than one issue
what does anti-mullerian hormone do
suppress oestrogen
how should you investigate a disordered ovulation cycle
Progesterone levels :
Elevated serum progesterone in mid-luteal phase suggests ovulation
Women with irregular cycles need this repeating
USS
Monitor corpus luteum and follicle
Raerely done
Urine predictor kit
Measures LH surge
Ovulation should follow
what is a polycystic ovary
appearance of multiple (>12) small (2-8mm) follicles in an enlarged ovary (>10ml)
what is the prevalence of polycystic ovaries (not PCOS) in women who regularly ovulate
20%
what is the diagnostic criteria for PCOS
2/3 of:
Polycystic ovaries on USS irregular periods (>35 days apart) Hirsutism (clinical or biochemical)
what is the pathology of PCOS
increased LH/peripheral insulin resistance leading to increased ovarian androgen production and reduced androgen binding products causing hirsutism and disregulated ovulation/folliculogenesis
what are the typical features of a patient with PCOS
acne overweight hirsutism amenorrhea/oligomenorrhea may have had miscarriages
how should you investigate PCOS
anovulation bloods: FSH (raised in ovarian failure, normal in PCOS)/AMH (raised in PCOS)/Prolactin/TSH
serum testosterone
LH (often raised but not diagnostic
Transvaginal USS
diabetes/lipids screen may be a good idea too
what are the complications of PCOS and the prevalence of the complications
t2dm - 50%
gestational diabetes - 30%
endometrial CA - 6x increase
what is the treatment for PCOS
weight reduction advice - 1st line
COCP if fertility not required - 1st line
anti-androgens (spironolactone, cytoproterone) - typically 2nd line
Clomifine - if fertility required
Metformin - if fertility required but normally used as a 1st line adjunct
eflornithine - topical anti-androgen used for facial hirsutism
what are some causes of anovulation
hypothalamic hypogonadism kallman's syndrome hyperprolactinaemia premature ovarian insufficiency gonadal dysgenesis lutenised unruptured follicle syndrome hyper/hypothyroidism androgen secreting tumours
what typically causes hypothalamic hypogonadism
anorexia
excess exercise
stress
what is Kallman’s syndrome
occurs when GnRH-secreting neurones fail to develop
how do you treat Kallman’s syndrome
exogenous gonadotrophins or GnRH pump
bone protection via COCP/HRT
what are features of hyperprolactinaemia
amenorrhea/oligomenorrhea
galactorrhea
headaches/bitemporal hemianopia if prolactinoma
what are the common causes of prolactinaemia
prolactinoma of the pituitary pituitary hyperplasia hypothyroidism PCOS psychotropic drugs
how do you treat prolactinaemia
dopamine agonists (bromocriptine/cabergoline)
surgery if necessary
what blood results indicate premature ovarian insufficiency
high FSH/LH, low AMH
what is required when treating premature ovarian deficiency?
bone protection - via COCP/HRT
what is lutenised unruptured follicle syndrome + what is its progression
follicle develops but the egg is never released
unlikely to occur every month so not too much to worry about
how do you choose between clomifine and metformin when treating fertility in women with PCOS
metformin works better in patients with a BMI <30 and can be used for longer - clomifine is limited to 6 months use
when in the menstrual cycle is clomifine best given
2-6 days
how should you follow up the use of clomifine in PCOS
transvaginal USS to asses endometrial thickness (causes thinning) and follicular development
none = up dose >3 = reduce dose
what is an alternative surgical procedure for PCOS
laporoscopic ovarian diathermy
what are side effects of ovulation treatment/induced ovulation
multiple pregnancy
ovarian hyperstimulation syndrome
what is on ovarian hyperstimulation syndrome
overgrowthof the follicles which can cause considerable pain
what are some risk factors for the development of ovarian hyperstimulation syndrome whilst taking gonadotrophins
<35
previous OHSS + PCO
what are complications/severe symptoms of ovarian hyperstimulation syndrome
hypovolaemia electrolyte disturbance ascites thromboembolism pulmonary oedema
what hormone is spermatogenesis mainly reliant on
LH (testosterone) and FSH
how does LH and FSH affect spermatogenesis and what cells do they act on
LH controls hormone production via leydig cells
FSH/testosterone controls sperm production and transport via sertoli cells
how long does it take sperm to develop fully grown sperm
70 days
what are the components of semen analysis and their normal ranges
volume of semen - 1.5ml
sperm count - >15million/ml
progressive motility - >32%
what is the definition of azoospermia
no sperm present
what is the definition of oligospermia
<15million/ml
what is the definition of severe oligospermia
<5million/ml
what is the definition of asthenospermia
absent or low motility
what may cause abnormal/absent sperm release
idiopathic drug exposure - alcohol, smoking, sulfasalazine, anabolic steroids varicocele anti-sperm antibodies infections genetic abnormalities hypothalamic issues kallmans syndrome hyperprolactinaemia retrograde ejaculation
how should you investigate azoospermia
azoospermia - FSH, LH, Testosteronem prolactin and TSH:
hypothalamic hypogonadism - low LH/FSH/testosterone
hyperprolactinaemia/thyroid issues are relative obvious
primary testicular failure - high FSH and LH, low testosterone
serum karyotyping - e.g. XXY in kleinfelters
cystic fibrosis testing if absent vas deferens
how should you manage male subfertility
General advice:
Stop smoking/drinking
Avoid aggravating drugs
Wear loose clothing to prevent testicular heating
Specific measures
Hypogonadotropic hypogonadism can be treated with 6-12 months of exogenous FSH/LH (+/- HCG) injections 3x a week
Assisted conception
what is the protocol for artificial insemination with male infertility
Intrauterine insemination works for mild-moderate oligospermia
IVF is reserved for more severe oligospermia
Intracytoplasmic sperm injection (ICSI) is used as part of the IVF cycle for even more severe cases
Surgical sperm retrieval may be used if there is azoospermia then use ICSI-IVF
what are some common causes of failure to join the sperm to egg (failure to fertilise)
PID Endometriosis - 25% of all subfertile women Previous pelvic surgery/sterilisation cervical problems - rare sexual problems
what are the options for detecting tubal damage when investigating failure to fertilise
Laparoscopy and dye test
Methylene blue injected into cervix and tubes are observed
If dye spills out they are patent , if it doesn’t they are not
Hysterescopy
Performed to assess any uterine abnormalities
Hysterosalpingogram
Radio-opaque dye injected into the cervix
Fimbral spilling seen on xray
Less invasive version done with a transvaginal USS but this does not pick up endometriosis or periovarian adhesions
what are the current types of assisted conception
Intrauterine insemination IVF +/- in vitro fertilisation frozen embryo replacement oocyte donation preimplantation genetic diagnosis
what is intrauterine insemination
washed sperm are injected directly into the uterine cavity
performed during a natural ovarian cycle - identified by urinary LH testing
what kinds of couples is intrauterine insemination right for
Unexplained subfertility
Sexual issues
Cervical problems
Male factor problems
whats the live birth rate for intrauterine insemination
10-15%
what is in vitro fertilisation +/- intracytoplasmic sperm injection
embryos are fertilised outside the uterus and implanted back in
what is the age stratified live birth rate for IVF +/- ICSI
<36 - 35%
40 - <10%
what is required of the ovaries before IVF may be started, and how is this measured
a normal ovarian reserve - meaning it cant be done in those with ovarian failure
anti-mullerian hormone
what are the 4 stages of IVF
multiple follicular development
ovulation and egg collection
fertilisation and culture
embryo transfer
what are the different protocols for the multiple follicular development stage of IVF
Long Protocol
2-3 weeks of GnRH is used to suppress the pituitary FSH/LH production and cause ovarian suppression
Once suppression is confirmed by endometrial thinning or low oestrogen levels FSH/LH can begin
The GnRH is continued until follicle collection
Short protocol
Pituitary suppression not achieved before FSH/LH injections
Instead a GnRH antagonist is added 5 days into the FSH/LH regime and continued until collection
what is used to mature follicles for IVF
bHCG or LH
what is the twin pregnancy rate for IVF
25%
what should be given to women before they take in donated oocytes
oestrogen and progesterone to prepare her endometrium
what is preimplantation genetic diagnosis used for
couples with known genetic abnormalities
what are complications of assisted conception
superovulation - multiple pregnancy and ovarian stimulation
egg collection - intraperitoneal infection and haemorrhage are risk of this procedure (only 1%)
pregnancy complications - increased rate of ectopic pregnancy
what is the live birth rate for a single IVF cycle with frozen eggs
30-50% (<37yrs)
