Fertility Medicine Flashcards
What three things are needed to become pregnant and thus where can things go wrong?
Functioning menstrual cycle (regular ovulation and thickened endometrium)
A healthy sperm
A healthy uterus and fallopian tubes
When, in the menstrual cycle, is fertilisation most likely to occur?
Day 14 (i.e. the day of ovulation)
What do we class as sub-fertility and how many couples will experience sub-fertility?
This is when a couple has been actively trying for a year and haven’t conceived
This will be the case for 15% couples
What is the difference between primary and secondary sub-fertility?
Primary is when the woman has never been pregnant
Secondary is when the women has had a pregnant before of any kind (could be miscarriage or TOP)
What things should you cover in the history of someone who is experiencing sub-fertility?
- Primary or secondary (ever been pregnant before)
- How often are they having sex? Any problems with sex (we recommend 2-3 times a week)
- How long have they been trying for
- Ages of the man and woman
- Menstrual hx (when is period, how long is cycle etc)
- Gynae hx
- Smear hx
- PMH
- SH (recreational drugs, urine will be sent to toxicology - if yes not eligible for IVF)
- DH
What lifestyle factors can you advice for a couple trying to get pregnant?
- Both couples should stop smoking and reduce alcohol (women should stop alcohol)
- Take plenty of regular exercise
- Reduce BMI if above 30 or increase if below 19
400mcg of FOLIC ACID
What are your chances of becoming pregnant within 2 years if you are 19-26?
98%
What are your chances of becoming pregnant within 2 years if you are 35-39?
90%
Which women should receive the larger dose of folic acid pre-conception and what is it?
Women with: Diabetes, Epilepsy, Coeliac disease, BMI >30 or previous child with NTD
5mg
What are the causes of sub-fertility and how common are they?
MALE CAUSES - 35%
OVULATION DISORDERS - 30%
PELVIC PATHOLOGY - 30%
Unknown - 5%
What are the leading causes of ovulatory disorder leading to sub-fertility?
PCOS
Premature ovarian insufficiency (premature menopause)
How do we diagnose PCOS?
USING THE ROTTERDAM CRITERIA (must have 2 out of 3 of):
- Oligo/anovulation
- Biochemical and/or clinical signs of hyperandrogenism (elevated free testosterone or hirsutism, acne or acanthuses nigricans)
- Polycystic ovaries (>12 follicles in each ovary)
What are the three types of issue that cause anovulation?
- Hypothalamic pituitary failure
- Hypothalamic-pituitary-ovarian disorder (PCOS)
- Ovarian failure
HYPERPROLACTINAEMIA
How do we treat hyperprolactinaemia?
Bromocriptine or surgery
What causes are there for the type 1 hypogonadotrophic disorders?
V LOW BMI is leading cause (low weight or excessive exercise)
if woman’s BMI is <19 then she should be encourage to put on weight
Can give exogenous steroids
How should we try and induce ovulation in a woman with PCOS?
- Try lifestyle interventions (lose weight, stop drinking/smoking)
- If still no ovulation detected give CLOMIPHENE … if this causes ovulation give 6-9 cycles and await conception
- Clomiphene + metformin OR gonadiotrophins OR ovarian drilling / diathermy … if ovulation deleted wait 6 cycles for conception
- If this still hasn’t worked then consider woman for IVF on NHS
How many women will go through the menopause before the age of 40?
1%
How do you diagnose premature ovarian insufficiency?
Different from diagnosing the menopause
- Oligo/amenorrhoea for 4 months
- Elevated FSH on at least 2 occasions more than 4 weeks apart
How do we treat premature menopause?
No treatments have been found to be effective
Women can be recommended to try egg donation
What are the most common causes of tubal infertility?
Adhesions from previous pelvic surgeries
PID (commonly from STDs e.g chlamydia)
What are some uterine causes of infertility?
FIBROIDS cause sub-fertility (treat with myomectomy)
Endometriosis can decrease fertility
Polyps
How should we investigate pelvic causes of infertility?
Hysteroscopy / hysterosalpingography - this is a good way to visualise the uterus and tubes to see if they are patent and working
Explorative laparoscopy
IF a couple are experiencing sub-fertility what full compliment of investigations should be offered?
Semenalysis for the male
STI tests and Rubella immunity offered as standard
Do a smear test
-PROGESTERONE 7 DAYS FROM END OF CYCLE (tell us whether she is ovulating or not)
Take FSH, LH and estradiol levels
Prolactin
Total serum testosterone
Thyroid levels
Hysterosalpingogram - inject dye into uterus
What do we measure in semenalysis?
Volume Count Motility (progressive and total) Morphology Concentration Vitality
What % of sperms have to be morphologically normal to have adequate sperm?
4%
What questions is it important of men experiencing sub-fertility?
Any conception before Any problems with erections or ejaculation Any hx of trauma to the area Any surgery to the area Any STIs Any swelling Ever had mumps? Ever had chemo or radiotherapy PMH: TB, DM, Sarcoidosis, obesity or CF DH: prescribed/non-prescribed/recreational/steroids Lifestyle - smoking, alcohol, occupation
What investigations should we offer to men experiencing sub-fertility?
Semen sample
FHS and LH and testosterone levels
Check for chromosomal abnormalities (Klinefelter’s)
Transrectal and testicular USS
What are some causes of sub-fertility in the male?
Idiopathic / unknown Hypogonadism Genetic cause Testicular trauma / surgery Exogenous anabolic steroid use Previous chemotherapy Vas defers problems (gonorrhoea, obstruction, CF)
When do we offer artificial aid with fertilisation and what are the options?
Usually after 2 years of trying with no success (age-dependent)
Can offer IVf or IUI
How does IVF work?
Woman given high levels of exogenous gonadotrophins to recruit multiple ovarian follicles
GnRH analogues given to stop woman ovulation (prevent LH surge)
Follicles monitored using USS
Once oocytes matured give them hCG, GnRH agonists and Kisspeptin
Oocytes then harvested transvaginally
Fertilisation done in petri dish
20% success rate
What are some side effects of IVF on the woman?
Abdominal bloating and mild abdominal pain
Ascites and thromboembolism
What pregnancy complications are more common in women using donor eggs?
Hypertensive disease of pregnancy is more common
Pre-term birth and LBW are also more common
Define terato -spermia olio -spermia aesthno-spermia aooz-spermia
terato -spermia (not normal)
olio -spermia (too little)
aesthno-spermia (low motility)
aooz-spermia (no sperm)
