Infertility Flashcards
What is infertility?
The inability to conceive over a 12 month period despite exposure to regular, unprotected sexual intercourse
How many couples are affected by infertility?
One in seven couples
What percentage of couples conceive within one year?
84%
What percentage of couples conceive within two years?
92%
What is primary infertility?
It refers to a patient who’s never conceived a child in the past experiencing fertility issues
What is secondary infertility?
It is the inability to conceive after previously giving birth to a baby – either in this relationship or a previous one
What are the five causes of infertility?
Sperm Problems
Ovulation Issues
Tubal Problems
Uterine Problems
Unexplained
What percentage of infertility issues are caused by sperm problems?
30%
What percentage of infertility issues are caused by ovulation problems?
25%
What percentage of infertility issues are caused by tubal problems?
15%
What percentage of infertility issues are caused by uterine problems?
10%
What percentage of infertility issues are unexplained?
20%
What are the four risk factors of infertility?
Age
Smoking
Alcohol
Obesity
What are the four risk factors of infertility?
Age - A woman’s fertility gradually declines with age, specifically after the mid 30s
Smoking
Alcohol
Obesity
Why does a woman’s fertility decrease with age?
This is due a decrease in the ovarian reserve and a decrease in the quality of the eggs
Why does smoking increase the risk of infertility in females?
It accelerates the decline in the ovarian reserve in females
Why does smoking increase the risk of infertility in males?
It decreases the sperm count in men
Why does obesity increase the risk of infertility in females?
It decreases the quality of eggs
Why does obesity increase the risk of infertility in males?
It decreases sperm count
When do we refer patients to a fertility clinic?
When there has been no conception after one year of regular unprotected intercourse
This can be reduced to six months if the woman is older than 35 years old or there is a known cause of infertility
What are the five investigations used to diagnose female infertility?
Blood Tests
Chlamydia Screening
Ultrasound Scan
Hysterosalpingogram
Laparoscopy Dye Test
What are the six blood tests used to diagnose infertility in females?
Serum LH Levels
Serum FSH Levels
Anti-Mullerian Hormone
Serum Progesterone Levels
Serum Prolactin Levels
Thyroid Function Test
When do we measure LH levels to diagnose infertility?
On day one to five of the menstrual cycle
How are LH levels used to help investigate infertility?
A high LH may suggest polycystic ovarian syndrome, which is a condition associated with infertility
What is the normal LH level?
Under 10miu/ml
When do we measure FSH levels to diagnose infertility?
On day one to five of the menstrual cycle
How are FSH levels used to help investigate infertility? Why?
A high FSH may suggest a poor ovarian reserve
This is because is indicates the pituitary gland is producing excess FSH in an attempt to stimulate follicular development
What is anti-mullerian hormone?
It is the most accurate marker of ovarian reserve
It is a hormone released by the granulosa cells in the follicles and falls as the eggs are depleted
What are the normal levels of anti-mullerian hormone?
These levels should be between 1.5-4 ng/ml in women under the age of 35
How are anti-mullerian hormone levels used to help investigate infertility?
A high level indicates a good ovarian reserve
A low level indicates a low ovarian reserve
When do we measure progesterone levels to diagnose infertility?
They should be measured seven days prior to the expected next period
In a typical 28 day cycle, this is conducted on day 21
How are progesterone levels used to help investigate infertility?
This test is used to determine if the process of ovulation is occurring as at this point in the cycle, ovulation should’ve occurred, and levels should be at peak
What are the normal levels of progesterone?
Over 30nmol/L
How is an ultrasound scan used to investigate infertility?
It is used to assess the antral-follicular count, which is the number of follicles present in the ovary
It is also used to determine the presence of any uterine or ovarian disease
How is a hysterosalpingogram used to investigate infertility?
It is a type of scan used to assess the shape of the uterus and the patency of the fallopian tubes
Describe the procedure of a hysterosalpigogram
It involves the insertion of small tube into the cervix
A contrast medium, methylene blue dye, is injection through the tube and fills the uterine cavity and fallopian tubes
An x-ray image is taken with the contrast giving an outline of the uterus and tubes
What hysterosalpingogram result indicates infertility?
If the dye doesn’t fill one of the tubes, tubal obstruction is indicated
When is hysterosalpingogram contraindicated?
Gynaecological problems
Pelvic infections
How is a laparoscopy dye test used to investigate infertility?
It is a type of scan used to assess the shape of the uterus and the patency of the fallopian tubes
Describe the procedure of a laparoscopy dye test
During the procedure, a laparoscope is inserted into the uterus to observe the pelvis organs
A methylene blue dye is then injected into the uterus
What laparoscopy dye test result indicates infertility?
This dye should spread into the fallopian tubes; however, this will not occur if there is obstruction present
What investigation is used to investigate male infertility?
Semen Analysis
How is semen analysis used to investigate infertility?
It is used to examine the quantity and quality of the semen and sperm
What is the normal semen volume?
> 1.5ml
What is the normal semen pH?
> 7.2
What is the normal sperm concentrations?
> 15 million per ml
What is the normal sperm motility percentage?
> 40%
What is the normal sperm morphology percentage?
> 4%
What is anovulation?
The lack or absence of ovulation
What is the most common cause of anovulation?
Polycystic ovarian syndrome
Which investigation result indicates that infertility is due to anovulation?
When serum progesterone levels are low
How do we conservatively manage anovulation?
It involves advising patients about weight loss, through a balanced diet and regular exercise
What is the first line treatment option for anovulation in overweight patients with polycystic ovarian syndrome?
Conservative management
What three drugs are prescribed for anovulation? What is their function?
Clomiphene
Letrozole
Gonadotrophins
These medications stimulate ovulation in a regular and cyclical manner
How do we surgically manage anovulation?
Laparoscopic ovarian drilling
What is laparoscopic ovarian drilling?
The surgeon punctures multiple holes in the ovaries using a surgical needle or laser therapy
What are the two sperm problems that cause infertility?
Low sperm count
Azoospermia
What are the two causes of sperm problems?
Insufficient hormone production
Testicular problems
Which investigation result indicates that infertility is due to sperm problems?
It is indicated by abnormal semen analysis results
What class of drugs are prescribed for sperm problems? What is their function?
It involves prescription of gonadotrophins
These medications increase hormone synthesis production
What are the three surgical procedures used to manage sperm problems?
Surgical Sperm Retrieval
Intrauterine Insemination
Intracytoplasmic Sperm Injection (ICSI)
When is surgical sperm retrieval conducted?
It is used when there is a blockage somewhere along the vas deferens preventing sperm from reaching the ejaculated semen
How is surgical sperm retrieval conducted?
The procedure involves a needle and syringe collecting sperm directly from the epididymis through the scrotum
What is intrauterine insemination?
It involves collecting and separating out high-quality sperm, then injecting them directly into the uterus to give them the best chance of success
This can be done with the male partner’s sperm or a donor’s sperm
What is ICSI?
It involves injecting a single sperm directly into the cytoplasm of an egg
The sperm selected is of the highest quality
These fertilised eggs become embryos and are injected into the uterus of the woman
In which three circumstances is ICSI conducted?
When there are significant motility issues
A very low sperm count
When there are other issues with the sperm
What are the three surgical procedures used to manage fallopian tube problems?
Tubal Cannulation
Endometriosis Ablation
In Vitro Fertilisation (IVF)
What is tubal cannulation?
It uses hysteroscopy to guide a cannula through the cervix and the uterus into the fallopian tube
This increases the patency of the fallopian tube
When is tubal cannulation conducted?
The procedure should only be conducted in those with mild blockage in the distal part of their fallopian tube
What is endometriosis ablation?
It is a procedure that surgically ablates the endometrium
What procedure is most commonly used to manage fallopian tube problems?
IVF
What is IVF?
It involves mature eggs being collected from the ovaries and fertilised by sperm in a lab
The fertilised eggs are then transferred to a uterus
This procedure can be conducted with the partner’s own egg and sperm; however, donor options are also available
How are uterine problems managed?
They are managed by removal of polyps, adhesions or other structural abnormalities affecting fertility
How do we manage infertility when there is an unexplained cause?
IVF
What are the seven steps of IVF?
Menstrual Cycle Suppression
Ovarian Simulation
Oocyte Collection
Oocyte Insemination
Embryo Culture
Embryo Transfer
Pregnancy
What are the seven steps of IVF?
Menstrual Cycle Suppression
Ovarian Simulation
Oocyte Collection
Oocyte Insemination
Embryo Culture
Embryo Transfer
Pregnancy
How is the menstrual cycle suppressed before IVF?
The prescription of GnRH agonists or GnRH antagonists
What GnRH agonist is prescribed before IVF? How is it given?
Goserelin
An injection of a goserelin is given in the luteal phase of the menstrual cycle, around 7 days before the expected onset of the menstrual period
How does a GnRH agonist suppress the menstrual cycle?
It initially stimulates the pituitary gland to secrete a large amount of FSH and LH
However, after this initial surge in FSH and LH, there is negative feedback to the hypothalamus, and the natural production of GnRH is suppressed
What GnRH antagonist is prescribed before IVF? How is it given?
Cetrorelix
Daily subcutaneous injections of cetrorelix are given starting from fay 5-6 of ovarian stimulation
When do we stimulate the ovaries for IVF?
This starts at the beginning of the menstrual cycle
How do we stimulate the ovaries before IVF?
FSH subcutaneous injections
How long do we stimulate the ovaries before IVF?
10-14 days
At what follicle size do we stop ovarian stimulation?
18mm
After the FSH injections, what other drug do we use to stimulate the ovaries?
An injection of hCG
When are hCG injections given before IVF?
This injection is given 36 hours before collection of the eggs
Why do we give hCG injections before IVF?
The hCG stimulates the final maturation of the follicles, ready for collection
How are oocytes collected?
A needle is inserted through the vaginal wall into each ovary to aspirate the fluid from each follicle under guidance of a transvaginal ultrasound scan
This fluid contain the mature oocytes from the follicles
When do we ask males to produce a semen sample for IVF?
Around the time of oocyte collection
Frozen sperm from earlier samples may be used
What two fertilisation methods are used for IVF?
Insemination
Intracytoplasmic Sperm Injection (ICSI)
What is insemination?
It involves the sperm being mixed in a culture dish which contains the collected egg
How long are fertilised eggs incubated for?
Over 2-5 days
At what development stage do we transfer the embryos from incubation to the uterus? When does this usually occur?
Blastocyte
Day five
What is the maximum incubation period for IVF?
6 days
How are embryos transferred to the uterus for IVF?
A catheter is inserted under ultrasound guidance through the cervix into the uterus
A single embryo is injected through the catheter into the uterus, and the catheter is removed
What do we do with the remaining fertilised eggs after embryo transfer?
The remaining embryos can be frozen for up to ten years in case of future attempt
When is a pregnancy test conducted after IVF?
16 days after egg collection
When do we prescribe progesterone during IVF?
From the time of oocyte collection until 8-10 weeks’ gestation
In what form is progesterone prescribed for IVF?
Pessary
Why do we prescribe IVF patients progesterone?
This is used to maintain the endometrium
Why do we no longer prescribe IVF patients progesterone after 8-10 weeks gestation?
From 8-10 weeks, the placenta takes over the production of progesterone
When is an ultrasound scan conducted after IVF? Why?
7 weeks gestation
To check for a fetal heartbeat and rule out miscarriage or ectopic pregnancy
What are the four complications of IVF?
Ovarian Hyperstimulation Syndrome
Multiple Pregnancy
Ectopic Pregnancy
Failure
