Infertility Flashcards
What is infertility?
It is defined as inability of a couple to conceive after 12 months of regular intercourse without use of contraception.
How common is infertility?
1 in 7 couples report infertility problems
What is the chance of conception?
Over 80% of couples in the general population will conceive within 1year if
- Women <40 years old
- Do not use contraception
- Having regular sexual intercourse
Of those who do not conceive in the first year, about half will do so in the second year (cumulative pregnancy rate over90%).
When should you investigate for infertility?
If haven’t conceived within 1 year despite actively trying
What are the 4 questions surrounding the cause of fertility problems?
- Are eggs available?
- Are sperm available?
- Can they meet?
- Can embryo implant ?
What should you ask about when taking a female’s history?
- Duration of infertility
- Previous contraception
- Fertility in previous relationships
- Previous pregnancies and complications
- Menstrual history
- Medical and surgical history
- Sexual history
- Previous investigations
- Psychological assessment
What examination should a female undergo?
- Weight
- Height
- BMI (kg/m2)
- Fat and hair distribution
- Galactorrhoea
- Abdominal examination
- Pelvic examination
What is hirsutism caused by?
Andorgen excess
What scoring system is used for androgen excess?
Ferriman Gallwey score
What biochemical measurents are carried out in androgen excess?
- Testosterone (T)
- Dehydroepiandrosterone sulphate (DHEAS) if is greater than 700 mcg/dL (18.9 micromol/L) adrenal computed tomography (CT) is recommended to look for an androgen-secreting adrenal tumor
- 17-OH Progesterone
Name a skin sign of androgen excess.
Acanthosis nigricans
What is looked for on pelvic examination of a female?
- Masses
- Pelvic distortion
- Tenderness
- Vaginal septum
- Cervical abnormalities
How can fibroids present?
- Pressure symptoms
- Period problems
- Infertility
What baseline investigations are done for the female?
- Rubella immunity,
- Chlamydia
- TSH
- If periods are regular: Mid luteal progesterone ( 7 days prior to expected period);
- If periods are irregular please do day 1-5 FSH, LH, PRL, TSH, testosterone
What baseline investigation is carried out on the male?
Semen analysis
What investigations are carried out at the fertility clinic?
- Pelvic Ultrasound
- Physical examination
- Testing for ovulation
- Semen analysis repeat if required
- Tubal patency test
What should women who are concerned about their fertility be asked about?
Frequency and regularity of menstrual cycles
If a women is having regular menstrual cycles, what is unlikely to be the cause of infertility?
Ovulation
How is ovulation confirmed?
A blood test to measure serum progesterone in the mid-luteal phase of their cycle (day21 of a 28‑day cycle) to confirm ovulation even if they have regular menstrual cycles
What should women who have prolonged irregular menstrual cycles be offered?
- A blood test to measure serum progesterone.
- Depending upon the timing of menstrual periods, this test may need to be conducted later in the cycle (for example day28 of a 35‑day cycle) and repeated weekly thereafter until the next menstrual cycle starts
What should women with irregular menstrual cycles be offered?
A blood test to measure serum gonadotrophins (FSH and LH )
How are tubal and uterine abnormalities screened for?
- Hysterosalpingography
- HyCoSy
Who should be offered hysterosalpinography?
Women who are not known to have comorbidities (such as pelvic inflammatory disease, previous ectopic pregnancy or endometriosis)
Why is a hysterosalpingogram carried out?
To screen for tubal occlusion because this is a reliable test for ruling out tubal occlusion, and it is less invasive and makes more efficient use of resources than laparoscopy.
What is important to ask about in the male history?
Developmental (Testicular descent, change in shaving frequency, loss of body hair )
Infections (mumps , STIs)
Surgical (varicocele repair, vasectomy)
Previous fertility
Environmental (alcohol, smoking, anabolic steroids, chemotherapy, radiation, drug use)
Sexual history (libido, frequency of intercourse, previous fertility assessment)
Any chronic illness
What is carried out for examination of the male?
- Weight
- Height
- BMI (kg/m2)
- Fat and hair distribution (hypoandrogenism)
- Abdominal and inguinal examination
- Genital examination (epididymis, testes, vas deferens, varicocele)
What is the most common cause of epididymitis?
STI
- Chlamydia
- Gonorrhoea
What is a varicocele?
- A dilatation of the pampiniform plexus of the spermatic veins in the scrotum.
- Most men with varicocele and presumptive infertility have abnormal semen parameters, including low sperm concentration and abnormal
Why should men with varicocele not be offered surgery as fertility treatment?
Does not improve fertility rates
What is one of the most common causes of primary hypogonadism (impaired spermatogenesis and testosterone deficiency)?
Klinefelter syndrome
What is Klinefelter syndrome characterised by?
- Sex chromosome aneuploidy, with an extra X (XXY) chromosome being the most frequent.
- These patients often have very small testes and almost always have azoospermia
What is the incidence of Klinefelter syndrome?
- 1 out of 500 to 700 phenotypic males
- Up to 10 to 15 percent of infertile men with azoospermia
What can lead to congenital bilateral absence of the vas deferens?
Cystic fibrosis mutations
What are the lower lab levels for sperm analysis?
- Semen volume (1.5ml)
- Sperm concentration (15 million/ml)
- Total sperm number (39 million)
- Progressive motility (32%)
- Total motility (40%)
- Morphologically normal (4%)
When should infertility be referred to clinic before 1 year of trying?
- Period irregularity
- Past medical history
- Testicular problems
- Abnormal tests
- HIV/Hep B
- Anxiety
Age
- 35-45 (after 6 months)
- > 45 years little can be offered
What are the 3 groups of ovulatory disorders?
Group 1
-Hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism).
Group 2
-Hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome).
Group 3
-Ovarian failure (POI)
What advise should women with group 1 ovulation disorders be given?
They can improve their chance of regular ovulation, conception and an uncomplicated pregnancy by:
-Increasing their body weight if they have a BMI of less than19 and/or
moderating their exercise levels if they undertake high levels of exercise.
What medication should women with group 1 ovulatory disorders be given?
Pulsatile administration of gonadotrophin-releasing hormone or gonadotrophins with luteinising hormone activity to induce ovulation.
What is the triad of PCOS?
- Androgen excess
- Infrequent periods
- Polycystic ovaries
How is PCOS diagnosed?
- Clinical (hirsutism)
- Biochemical (testosterone levels)
- Anovulation
- Ultrasound
What is the general management for fertility issues related to ovulatory disorders?
- Treat underlying cause
- Weight loss/gain
- BMI >18 and <35
- Ovulation Induction by clomifene and gonadotrophins
How does clomifene work?
Blocks oestrogen receptors in the anterior pituitary, leading to increased secretion of FSH through loss of negative feedback
What is clomifene?
A selective oestrogen receptor modulator
What are the possible side effects of clomifene?
- Vasomotor
- Visual
How is clomifene use monitored?
- Follicle scanning in 1st cycle
- 15% will require a dose adjustment
What is the dose of clomifene?
50mg-150mg day 2-6
When are gonadotrophins used to treat infertility?
- No ovulation with Clomifene
- Ovulation but no pregnancy
What gonadotrophin therapy can be used?
- FSH by injection
- Up to 3-6 cycles
What should women with hydrosalpinges be offered?
A salpingectomy, preferably by laparoscopy, before IVF treatment because this improves the chance of a live birth.
What treatments are available to address male factors?
- Urologist referral if appropriate
- IVF/ICSI
- Intra-uterine insemination
- Reversal of vasectomy
- Surgical sperm retrieval
- Donor insemination
What are the post testicular causes of azoospermia?
- Iatrogenic
- Congenital
- Infective
How should azoospermia be investigated?
- History
- Examination
- FSH, LH, Testosterone, Karyotype, PRL
- CF screen
What should women with unexplained fertility be told?
- Inform women with unexplained infertility that clomifene citrate as a stand-alone treatment does not increase the chances of a pregnancy or a live birth.
- Advise women with unexplained infertility who are having regular unprotected sexual intercourse to try to conceive for a total of 2years (this can include up to 1year before their fertility investigations) before IVF will be considered.
What should women with unexplained infertility be offered?
IVF treatment
What should women with unexplained infertility not be offered?
Ovarian stimulation agents such as clomifene
Briefly describe IVF.
- Eggs harvested from ovary
- Eggs fertilised in the lab with sperm
- Embryos undergo a number of cell divisions
- Embryos transferred to the womb
What is intracytoplasmic sperm injection?
- Injection of mature eggs with single sperm
- Incubation overnight
What changes in society are leading to fertility issues?
- Single women
- Same sex couples
- Older women
- Obesity
What is primary infertility?
Infertility in someone who has never conceived before
How do you define irregular periods?
Periods which have variation of around 7 or more days per month
What criteria is used to diagnose PCOS?
Rotterdam criteria
What is first line fertility treatment in someone with PCOS?
Weight loss until normal BMI
What can cause tubal block in a female?
- Inflammatory disease
- STI
- Sterilisation
- Endometriosis
What is azoospermia?
Ejaculate with absence of sperm
What is unexplained infertility?
Unexplained infertility is when there is infertility without obvious disturbance to the eggs, sperm or tubes
How common is unexplained infertility?
In 1 in 3 couples who have infertility it is unexplained
