Fertility problems Flashcards
What is misoprostol?
synthetic Prostaglandin E 1 analogue
What are the lifestyle recommendations for fertility?
F 1-2 units 1-2 x week
M less than 3-4 units x day
No smoking (even passive)
Caffeine- no association
BMI 19-30
When to refer to fertility team?
No conception after 12/12 trying
6/12 if - over 36yo, unable to have VI, planned CT/RT, PCOS, Endometriosis
First-line fertility investigations
Semen analysis
Ovarian reserve
mid luteal progesterone ( 7/7 before day 1 ie d21)
What is normal semen analysis?
> 1.5ml
15 million sperm/ml
pH >7.2
40% motile or >32% progressive motility
4% normal form
58% live
How to manage abnormal semen analysis
repeat in 3/12
if oligo/azoospermia-> repeat ASAP +/- karyotyping
May be changes to Y chromosome but do not text as does not change rx
What is good ovarian reserve?
High:
AFC over 16 on day 3
AMH over 25
FSH <4
What is poor ovarian reserve?
Low:
AFC <4 on day 3 of cycle
AMH <5.4
FSH >8.9
How to interpret mid luteal phase progesterone?
> 30 would trigger ovulation
check FSH + LH if irregular cycles
Additional fertility investigations
Prolactin
TFT
HIV/HBV/HCV prior to rx
How to check reproductive organs for fertility?
HSG- tubal occlusion
May need lap if PID/Endo/ectopic in hx
nil evidence for OPH/pipelle
Always test for chlamydia before instrumenting
When to check rubella in fertility?
before trying
if -ve vaccinate 1/12 before trying
When to do surgery for male subfertility
If tubal blockage present
NOT for varicocele as not shown to improve fertility
When to do surgery for female subfertility
Adhesiolysis if amenorrheic
salpingectomy if bilateral hydrosalpinx
salpingography if proximal tubal occlusion
What is Sheehan’s Syndrome?
Severe PPH-> hypovolemic shock-> ischaemic necrosis of anterior pituitary
5 in 100000
What are the features of Sheehan’s Syndrome?
agalactorrhea, amenorrhea, hypothyroid, adrenal insufficiency/crisis
Reduction of hormones from anterior pituitary ( TFTs/LH/FSH/ACTH/PL)
treatment- thyroxine, GH, hydrocortisone, HRT
What is MRKH?
46xx
Mullerian agenesis
short vagina, no cervix/uterus
ovaries present
Can have SI via dilators and pregnancy via surrogacy
What is WHO group 2 subfertility?
eugonadoptrophic hypogonadism
eg PCOS
Weight loss if BMI >30
clomifene/metformin/both
drilling
gonadotropins
How to use clomifene?
only 6 cycles, check USS do not increase dose if no response
increased risk multip/OHSS
How to manage unexplained infertility?
clomifene will not work
IVF if no success after 2 years
Normal chances of conception
< 40= 80% at 1 year, 90% 2 years
>40 50% after 6 ICSI, 75% after 12 ICSI
How to treat male hypogonadotropic hypogonadism?
Gonadotropins
Do not give if idiopathic
When to use IUI
unable to have VI
Same sex couple
fresh >frozen
6 cycles, then investigate and give 6 more
then swap to IVF
Hypogonadotropic hypogonadism in females
Sheehan
kallmann
stress/exercise
pituitary tumors
Use a DA agonist eg ropinorole/pramipexole or pulsatile GnRH/Gns
Markers of success with IVF
Positive:
previous pregnancy and/or birth
Negative
BMI, age, alcohol, smoking, caffeine, previous failed cycles
IVF eligibility
F <40
>2 years UPSi and 12 cycles AI (6 IUI)
>if hit 40 during rx can continue cycle but do not give further
F 40-42
> 1 cycle if nil previous IVF/no evidence of low reserve
IVF funding
3 cycles (any previous private cycles count as one)
Treatment before IVF
pre treatment with NET to schedule a bleed (d1 withdrawal- d1)
GnRH agonist if low risk OHSS to avoid premature LH surge
trigger ovulation with HCG
conscious sedation for oocyte retrieval, implant if ET >5mm
IVF treatment by age
<37 1 embryo cycle 1, 1 good or 2 ok cycle 2, 2 cycle 3
37-39 1 good/2 ok cycle 1 and 2, 2 cycle 3
40-42 2 embryos
use progestogen for 8 weeks to support
When to use ICSI
poor sperm quality/fertilisation at IVF
increased rate of fertilisation than IVF alone but nil increased pregnancy rate
When to use donated oocytes
POI
Turner’s
CT/RT
Genetic disorder risk
When to wash sperm
PLWH + detectable VL
not for HBV/HCV- vaccinate/treat
What is letrozole?
aromatase inhibitor
off license in PCOS
reduces E to stimulate ovulation 1 in 30 twin (clomifene= 1 in 10)
Wash out period for GLP-1
Tirzepatide- 1/12
Semglutide- 2/12
Exenatide- 3/12
T, S, E
1, 2, 3
What is the chance of spontaneous conception in:
Turner’s
POI
Turners 2-7%
POI 5-10%
