Infertility Flashcards
How common is failure to conceive after 1 year?
Approx 15% couples
Up to 25% couples overall
Small increase in prevalence - greater proportion of couples seek help
Considerable psychological distress
What is the average age of first birth?
28.5
First time more babies born > 35 than < 20
What is more likely with increasing maternal age?
Miscarriage
Chromosomal abnormalities
Increased incidence of Down’s syndrome
Increased maternal risks of pregnancy
What are the potential causes of infertility?
Unexplained 25%
Ovulatory 25%
Tubal 20%
Male 30%
Uterine/peritoneal 10%
What are the important principles of care?
See both partners together
Explanation and written advice
Seen by specialist team
What are the psychological effects of fertility problems?
Relationship difficulties (frequencies of intercourse)
Support groups
Counselling
What is the initial advice to people with infertility problems?
80% couples < 40 will conceive in first year
Half remaining will conceive in second year
Inform effect of age
Preconception advice
Refer after one year
What are the female criteria for early referral?
Age > 35
Menstrual disorder
Previous abdominal/pelvic surgery
Previous PID/STD
Abnormal pelvic examination
What are the male criteria for early referral?
Previous genital pathology
Previous urogenital surgery
Previous STD
Systemic illness
Abnormal genital examination
What preconception advice should you give to couples struggling to conceive?
Intercourse 2-3x weekly
Folic acid 0.4mg (5mg high risk)
Smear
Rubella
Smoking cessation services
Pre-existing medical conditions
Drug history (prescribed/recreational)
Environmental/occupational exposure
Alcohol (women none)
Weight (BMI 18-30)
Name 3 reproductive disorders associated with obestiy
PCOS
Miscarriage
Infertility
Lower ART success
Obstetric complications
What affect does obesity have on reproductive success?
BMI > 30 - longer to conceive, lower success with IVF
Losing weight improves anovulation
BFS advice inappropriate to treat if BMI > 35
Men with BMI > 30 reduced fertility
What investigations should you do with a couple who have infertility problems?
Ovulation/ovarian function
Semen quality
Tubal patency + uterus
How do you check ovulation?
Mid-luteal progesterone
- < 16 anovulation
- > 16 but < 30 equivocal
- > 30 ovular
Don’t test - temp, LH urine test, TFTs, prolactin if ovulating, endometrial biopsy
How do you test ovarian reserve function?
FSH - > 8.9 low response, < 4 high response
Antral follicle count - < 4 low response, > 16 high response
Antimullerian hormones - < 5.4 low response, > 25 high response
What should you look for in semen analysis?
Count > 15m/ml
Motility > 40%
Morphology > 4%
Total > 39m
Repeat if abnormal
Anti-sperm antibodies not required
What initial investigations does the GP need to do before referral to NHS fertility clinic?
Hormone profile - D2, FSH, D21 prog
TFT, prolactin - if indicated
Rubella
Smear
Swabs
Semen analysis
What further investigations should you do for male infertility?
Clinical examination - secondary sexual characteristics, testicular size
If count < 5m/ml
- Endocrine (FSH, LF, test, prolactin)
- Karytotype
- CF screen
Testicular biopsy - azoospermia
Imaging - vasogram, USS, urology
Dedicated specialist infertility clinic
Tubal patency testing
Swabs before instrumentation
How can you treat male infertility?
Mild - intrauterine insemination
Moderate - IVF
Severe - intracytoplasmic sperm injection
Azoospermia - surgical sperm recovery, donor insemination
Surgery - correction of epidymal block, vasectomy reversal, varicocele no benefit
Heat - occupation
Underpants/boxers?
Smoking
Alcohol
Occupational exposure
How can you treat hypogonadotrophic hypogonadism?
Gonadotrophins
How can you treat hyperprolactinaemia?
Bromocriptine
What diet/supplements can you give men to help with infertility?
Folic acid 5mg
Zinc 55mg
What is group 1 anovulation?
Low FSH/LH/E2
What can cause group 1 anovulation?
Stress
Weight loss
Exercise
Kallman’s
How can you treat group 1 anovulation?
FSH + LH
GnRH pump
Normalise weight
What is group 2 anovulation?
PCOS
Normal FSH, USS, androgens
How can you treat group 2 anovulation?
Ovulation induction - clomifene
What is group 3 anovulation?
Menopause
High FSH
What is the treatment for group 3 anovulation?
Donor egg
How do you treat an adenoma producing prolactin?
Bromocriptine
How do you treat Sheenhan’s?
FSH, LH
How can you treat clomifene/metformin resistant PCOS?
Laparoscopic ovarian drilling
Gonadotrophin ovulation induction
What is the criteria for PCOS?
2/3 of
- Anovulation or oligo/amenorrhoea
- Polycystic ovaries on scan - one ovary/> 12 small follicles/vol > 10cc
- Raised androgens - clinical/biochemical, exclude adrenal cause
How can you treat PCOS?
Normalise weight
Clomifene/tamoxifen
- Up to 6 cycles
- Monitor (progesterone and USS)
- Inform of multiple pregnancy rate
- > 12 months ovarian cancer risk
Metformin
- Less effective than clomifene alone
- Less effective in obese
- May help clomifene resistant
- GI S/E
Where can you get tubal disease?
Proximal
Distal - hydosalpinx
Adhesions - ovarian, tubal
What can cause tubal disease?
Infections - chlamydia/gonorrhoea
Endometriosis
Surgical - adhesions, sterilisation
How can you treat tubual disease?
Tubal surgery - laparotomy/laparoscopy
Tubal catheterisation
IVF
Does the medical treatment for endometriosis increased chances of pregnancy?
No
What surgery can you do for endometriosis?
Laparoscopic treatment
- Ablation or resection of minimal and mild disease
- Increases pregnancy and live birth rates
Laparoscopic cystectomy for endometrioma
- Increased pregnancy rates compared with drainage and coagulation
What is the treatment for unexplained infertility?
Clomiphene
SIUI
IVF - recommended after 2 years of infertility
What can you do for assisted conception?
Ovulation induction
Stimulated intrauterine insemination
IVF
Donor insemination
Donor egg
Donor embryo
Host surgery
What are the stages of IVF?
Intracytoplasmic sperm injection
Surgical sperm recovery
Embryo freezing
Assisted hatching
Blastocyst culture
What are the risks of IVF?
Multiple pregnancy
Miscarriage
Ectopic
Foetal abnormality?
Ovarian hyperstimulation syndrome
Egg collection
Longer term - ?ovarian cancer
What patient factors can affect the success of IVF?
Age - increased risks of hypertension, diabetes, IUGR, operative delivery, thromboembolism, maternal death
Cause of infertility
Previous pregnancies
Duration of infertility
Number of previous attempts
Specific medical conditions
Environmental factors
What uterine abnormalities can you have?
Adhesions
Polyps
Fibroids
- Intramural - reduced chance of pregnancy with ART
- Submucous myoma - lower pregnancy rates
Septate uterus
Does a myomectomy improve chances of pregnancy?
Yes compared to untreated myomas
Why might you have intrauterine adhestions?
Previous uterine evacuation or surgery
What are intrauterine adhesions associated with?
Oligo-amenorrhoea
How common is a septate uterus?
2-3%
What is a septate uterus compared with?
RPL
Preterm birth
What IVF treatment is offered to women < 40?
3 full cycles
Stop once age = 40
What IVF treatment if offered to women 40-42?
1 full cycle if no previous IVF and no low ovarian reserve
