human infertility Flashcards
natural expectation of pregnancy
couple w no issues/underlying problems that would affect their fertility, ~80% pregnant within 1yr
expectation ~90% normal couples should achieve pregnancy by 2yr mark
when does decline in female fertility start
after 35yrs and after 40 fertility is very low level
problematic effects of age on female fertility
quantity of eggs
decline in quality of eggs - cell division/capacity of egg to perform well in terms of nuclear/genetic material division also declines
4 stages of natural conception
ovulation
sperm production
fertilisation
implantation
4 stages of natural conception: ovulation
egg produced cyclically
hypothalamo-pituitary-gonodal acis
4 stages of natural conception: sperm production
good sperm, swimming well
hormonal control must be intact
outflow tract of sperm must be patent for sperm to be produced and released
4 stages of natural conception: fertilisation
need sperm and egg to meet
fallopian tubes must be patent and functioning well
no ED or ejaculatory problems in male to adequate sperm is released into F reproductive tract
4 stages of natural conception: implantation
uterus has to be normal
what does natural conception rely on
functioning hormonal axis and gonads ovarian reserve regular ovulation normal sperm production - motile fertilisation - egg + sperm interaction and patent fallopian tube normal uterine cavity for implatation
lifestyle factors that can effect fertility in males and females
age BMI (females) smoking alcohol rec drug use stress?
clinical definition (WHO) of infertility
inability to conceive over a 12mo period despite exposure to regular, unprotected intercourse
represents a prognosis based approach and provides practical guidance on when to initiate investigations
epidemiological definition (WHO) of infertility
lack of conception after 2yrs in women of reproductive age (15-49) who are at risk of becoming pregnancy (sexually active, not using contraception)
demographic definition (WHO) of infertility
inability to become pregnant with a live birth, within 5yrs of exposure, based upon a consistent union status, lack of contraceptive use, non-lactation and continuation of a desure for a kid
when to refer
no conception after 1yr of unprotected intercourse
refer earlier if age>35yrs or known cause for infertility
primary infertility
never managed to have a pregnancy before/man never fathered a child
secondary infertility
couple have had a pregnancy before and now cannot get pregnant
female infertility causes
ovulation problems - may not release egg regularly, egg reserve low
fallopian tube problem
uterine factors
endometriosis
male infertility causes
hormone production that controls sperm release
issue with testicle
blockage sperm transport
ejaculation/erection problems
approach to infertility investigations - think broadly about 4 factors
are eggs available?
are sperm available?
can they meet?
any other factors?
infertility investigations: are eggs available
age
ovarian reserve test: FSH day 1-5 cycle, AMH
USS - antral-follicular count
infertility investigations: is ovulation happening?
natural methods: basal body temp, cervical mucus
LH ovulation kits
ovulation calandre
D21 serum progesterone - day 21 of 28/30 cycle
infertility investigations: are sperm available
semen analysis
infertility investigations: can egg and sperm meet
intercourse - woman having no pain/discomfort and man doesn’t have erection/ejaculation problem
patent fallopian tube
infertility investigations: how to check fallopian tube patency
hysterosaplingogram (HSG)
laparoscopic dye test
infertility investigations: other tests
serum prolactin
thyroid function test
chlamydia screening
pelvic USS for uterine problems
also check: rubella immunity and if cervical smear is up to date
management: ovulation disorders
optimise body weight, healthy lifestyle, exercise
medication - ovulation induction
- clomiphene citrate
- gonadotropins
laparoscopic ovarian drilling
management: low sperm count or no sperm (azoospermia)
management depends on what causing low sperm e.g. hormones, testicles etc.
medical: gonadotropins
surgical sperm retreival
donor sperm - intrauterine inseminsation
intracytoplasmic sperm injection
management: tubal problem
surgical approach: mild disease e.g. mild blockage or scar tissue
IVF
unresolved fertility then what
IVF - in vitro fertilisation
human fertilisation and embryology authority
regulatory authority licensing inspections forms: registration, treatment, outcome register
IVF
fertilising egg with sperm outside the body in the lab
IVF: own eggs
gonadotropin induced superovulation
gonadotropin injections, will produce multiple eggs in one cycle
IVF: donor eggs
age
poor quality
ovarian failure
genetic cause
IVF: partner’s sperm
fresh sample on day of egg collection
thawed frozen sample from surgical retrieval or fertility preservation
IVF: donor sperm
single woman same sex relationship azoospermia genetic cause infection (HIV, hep b/c)
IVF process: key steps
- controlled ovarian stimulation
- follicular monitoring
- timing ovulation
- egg collection
- lab fertilisation
- incubation/embryo development
- embryo transfer
- progesterone support
IVF: post embryo transfer
progesterone pessaries
normal activity
pregnancy test after 2wks
if positive then scan at 7wks
risks of IVF
ovarian hyper-stimulation syndrome
multiple pregnancy
medication side effects
procedure related - bleeding, infection
IVF expanding indications
donor gametes fertility preservation - gamete/embryo cyropreservation preimplantation genetic diagnosis assisted hatching in vitro maturation surrogacy
