Infertility Flashcards
What percentage of couples will conceive naturally after 1 yr of regular unprotected sex?
85%
What proportion of couples will struggle to conceive naturally
1 in 7
How long must couples try to conceive for without success before investigation and referral for infertility should be initiated?
> 12 months
or
6 months if the woman is >35yo due to reducing ovarian stores
List the causes of infertility
Sperm problems (30%) Ovarian problems (25%) Tubal problems (15%) Uterine problems (10%) Unexplained (20%)
What percentage of infertile couples have a mix of male and female causes?
40%
Give some general advice for couples trying to get pregnant
Woman should take 400mcg folic acid daily
Aim for healthy BMI
Avoid smoking and drinking excess alcohol
Reduce stress as this may negatively impact libido and relationship
Aim for intercourse every 2-3 days
Avoid timing intercourse
What investigations can be ordered for infertility in primary care?
BMI Chlamydia screen Semen analysis Female hormonal testing Rubella immunity in the mother
List the female hormones tested when investigating infertility
Serum LH and FSH (on days 2-5)
Serum progesterone on day 21 (or 7 days before the end)
Anti-Mullerian hormone
Thyroid function tests
Prolactin if symptoms of galactorrhoea or amenorrhoea
What does a high FSH indicate
Poor ovarian reserve - pituitary producing extra FSH in attempt to stimulate development
What does a rise in day 21 progesterone indicate?
Ovulation has occured - corpus luteum formed and secreting progesterone
When can anti-Mullerian hormone be measured?
Any time of cycle
What is anti-Mullerian hormone a marker of?
Ovarian reserve
What releases anti-Mullerian hormone?
Granulosa cells in the follicles
When does anti-Mullerian hormone decrease?
As the eggs are depleted
What investigations for fertility can be performed in secondary care?
Ultrasound pelvis - PCOS or any structural abnormality
Hysterosalpingogram - patency of fallopian tubes
Laparoscopy and dye test - patency of the tubes, adhesions and endometriosis
What is a hysterosalpingogram?
Scan used to assess the shape of the uterus and the patency of the fallopian tubes
What are the benefits of a hysterosalpingogram?
Diagnostic
Therapeutic - seems to increase rate of conception without any other intervention
Describe how a hysterosalpingogram is done
Small tube into cervix
Contrast medium injected through the tube and fills the uterine cavity and fallopian tubes
X-ray images are taken and the contrast shows up on the X-ray giving an outline of the uterus and tubes
If dye does not fill a tube then will suggest tubal obstruction
What are the risks of hysterosalpingogram?
Infection risk
Describe the laparoscopy and dye test
Patient admitted for laparoscopy
During procedure, dye is injected into the uterus and should be seen entering the fallopian tubes and spilling out of the end of the tubes
This will not be seen in tubal obstruction
During laparoscopy, the surgeon can also assess for endometriosis or pelvic adhesions and treat these
Describe the management of anovulation
Weight loss Clomifene Letrozole Gonadotrophins Ovarian drilling Metformin
What is clomifene
Anti-oestrogen (selective oestrogen receptor modulator)
Given on days 2 to 6 of the menstrual cycle
Stops the negative feedback of oestrogen on the hypothalamus resulting in greater GnRH release and subsequently FSH and LH
Describe ovarian drilling
Laparoscopic surgery
Surgeon punctures holes in the ovaries using diathermy or laser therapy
Can help improve hormone profile and result in regular ovulation and fertility
List some management options of tubal factors
Tubal cannulation during hysterosalpingogram
Laparoscopy to remove adhesions or endometriosis
IVF
List some management options of uterine factors
Surgery to correct polyps, adhesions or structural abnormalities
List the management of sperm problems
Surgical sperm retrieval Surgical correction Intra-uterine insemination Intracytoplasmic sperm injection Donor insemination
Describe surgical sperm retrieval
Used when there is a blockage somewhere along the vas deferens preventing sperm reaching the ejaculated semen
A needle and syringe is used to collect sperm directly from the epididymis through the scrotum
