Fertility and subfertility Flashcards
What is the definition of subfertility? Primary vs. secondary?
Couple unable to conceive for more than a year of unprotected sex.
Primary = never conceived.
Secondary = previously conceived, regardless of outcome.
What are the four gross conditions required to conceive?
1) need an egg
2) need sperm
3) need to get them together
4) need to implant the egg
How do you detect ovulation?
Raised serum progesterone in luteal phase indicates ovulation has occured.
USS to monitor follicular growth.
What are the main causes of anovulation?
PCOS - 80% of cases.
Hypothalamic: Hypothalamic hypogonadism, Kallman’s syndrome.
Pituitary: Hyperprolactinaemia, Pituitary damage.
Ovarian: Premature ovarian failure, Gonadal dysgenesis.
Other: Hypo/hyperthyroidism, androgen secreting tumours.
What are the diagnostic criteria for PCOS?
2/3 of:
Polycystic ovary on USS.
Irregular periods (>35d apart).
Hirsutism (acne, excess body hair; raised androgens on biochemistry).
How would you investigate anovulation / ?PCOS?
Bloods: FSH (raised in ovarian failure, low in hypothalamic disease, normal in PCOS), prolactin (exclude prolactinoma), TSH, testosterone (exclude androgen secreting tumour / congenital adrenal hyperplasia), LH (often raised, but not diagnostic).
USS to look for polycystic ovaries.
What are the complications of PCOS?
DM (50%), GDM (30%).
Endometrial cancer (due to unnoposed oestrogen).
What is the mechanism of PCOS?
Disordered LH production and insulin insensitivity.
This directly causes PCO and increased androgen production plus low steroid binding protein. Androgens then cause follicular immaturity and hirsutism.
How would you treat PCOS?
Decrease weight (beneficial to all PCOS symptoms).
COCP to regulate menstruation and hirsutism.
Also: cyproterone acetate or spironolactone (anti-androgens) good for hirsutism; Metformin good for insulin, therefore androgens and hirsutism.
How would you induce ovulation in PCOS?
1) Clomifene (antioestrogen) given on days 2-6 to initiate follicular maturation, which is then self perpetuating. Need to monitor with USS for under / over stimulation and endometrial thinning.
1a) Metformin may be added to clomifene or tried instead if clomifene failed.
2) Laparscopic ovarian diathermy.
2) Gonadatrophins (LH+FSH given, then LH).
How would you induce ovulation in hypothalamic hypogonadism?
Restore weight.
Gonadotrophins (FSH + LH). Daily injections.
What are the side effects of inducing ovulation?
Multiple pregnancy (clomifene and gonadotrophins).
Ovarian hyperstimulation syndrome (very large, painful follicles).
What are the common causes of male subfertility?
Idiopathic oligospermia, asthenozoospermia..
Drug exposure (alcohol, smoking, anabolic steroids).
Varicocoele.
Antisperm Abs.
Others: infections, mumps orchitis, Klinefelters, Obstruction to delivery, Kallman’s syndrome, retrograde ejaculation, hyperprolactinaemia.
How would you investigate male subfertility?
Semen analysis.
If azoospermia: FSH, LH, testosterone, prolactin, TSH, serum karyotype to find cause.
How do you manage male subfertility?
Lifestyle and drugs.
Hypothalamic hypogonadism - LH and FSH injections twice a week.
Assisted contraception techniques - IUI, IVF.
