infertility Flashcards
human fertility compared to other mammals
inefficient reproductive system
conception per cycle - 20% at peak age, declines with age
natural expectation of pregnancy
in a couple with no underlying fertility issues
80% of couples will become pregnant within the first year of trying
over 1/2 of the couples that didn’t get pregnant in the first year will get pregnant in the second year
90% of couples should achieve a pregnancy after 2yrs
why does female fertility decline
eggs production stops at birth
over the reproductive life span, the majority of the eggs perish with each cycle
fertility declines as egg numbers decline
eggs also don’t perform as well
begins after 35y/o
can we predict decline in fertility?
no
at the moment we can only plan ahead and use fertility tests (can’t determine if a women will get pregnant)
4 stages of conception
ovulation
sperm production
fertilisation
implantation
what does normal conception rely on
functioning hormonal axis and gonads ovarian reserve regular ovulation normal sperm production fertilisation: sperm and egg interaction, patent fallopian tubes normal uterine cavity for implantation
lifestyle factors affecting conception
age BMI smoking alcohol recreational drug use stress
clinical definition of infertility
inability to conceive over a 12mth period despite exposure to regular, unprotected intercourse
represents a prognosis based approach
provides practical guidance on when to initiate investigations
epidemiological definition of infertility
lack of conception after 2yrs in women of reproductive age (15-49) who are at a risk of becoming pregnant (sexually active, not using contraception)
demographic definition 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 desire for a pregnancy
global infertility trends
10% of woman affected globally, likely underestimated (based on demographic definition)
1/7 couples in western world, 1/4 couples in developing countries affected
difficulties with estimating prevalence of infertility
main challenge in getting true estimates is inconsistency in definition used to calculate prevalence
when to refer
no conception after 1yr of regular unprotected intercourse
referral earlier if:
- age >35
- known cause for infertility
types of infertility
1y - never managed to have pregnancy before/never fathered a child
2y - have had a pregnancy before/fathered a child but cannot manage again
causes of infertility
male - 30% female - 30% combined - 10% unexplained - 25% other - 5%
female infertility factors
ovulatory dysfunction 35% tubal factor 30% diminishing ovarian reserve 20% endometriosis - 10% uterine factor 5%
male infertility factors
hormone production
blockage of sperm transport
sperm production problems
erection and ejaculation problems
why may there be blockage of sperm transport
infection
prostate related problems
absence of vas deferens
vasectomy
why may there be issues with sperm production
genetic undescended testes infection torsion varicocele drugs radiation damage sperm antibodies heat
why may there be erection and ejaculation problems
prostate surgery damage to nerves ejaculation problems timing of intercourse medication
investigating infertility
are eggs available
are sperm available
can they meet
any other factor
investigating infertility - egg availability
age ovarian reserve test - bloods and scan bloods: - FSH, D1-D5 of cycle (<10iu/L) - AMH (5.0-25.0pmol/L)
US - antral follicular count
investigating infertility - is ovulation happening
used by couples:
- natural methods - BBT, cervical mucus
- LH ovulation kits
- ovulation calender
used to investigate:
- D21 serum progesterone
natural ovulation detection - basal body temperature
female checks temp
at the time of fertile window
at the time of progesterone rise (post-ovultation) - slightly higher temperatures can be recorded
fertile window is just before this
natural ovulation detection - cervical mucus
phase and stage, sensation, cervical fluid appearance
pre-ovulatory stage - dry-light moisture; INFERTILE; no observable mucus
fertile - moist/sticky; white/cream in colour, thick to a little stretchy, breaks easily when pulled
highly fertile - slippery, wet, lubricated; thin, watery, transparent, like egg white, increased amount
post-ovulatory - dry/moist/sticky; INFERTILEl thick, opaque white/cream, much decreased amount
LH kits
measures peak of LH
uses urine to measure
LH surge - fertile
ovulation diagnosis
progesterone levels taken at appropriate time - day 21 only if 28/30 day cycle
levels >20nmol/L show satisfactory ovulation
investigating infertility - sperm availability
semen analysis
parameters for semen analysis - lower limit normal, 95% confidence
volume - 1.5ml, 1.4-1.7ml total sperm number - 39mln, 33-46mln concentration - 15mln/ml, 12-16mln/ml vitality - 58%, 55-63% progressive motility - 32%, 31-34% total motility - 40%, 38-42% normal morphology - 4%, 3-4%
investigating infertility - can egg and sperm meet
intercourse - any difficulties, female or male
patent fallopian tubes
how to check fallopian tube patency
if no pelvic infection/gynae problem previously - hysterosalpingogram (HSG)
if any of above - laparoscopic dye test
HSG - what is done
small catheter inserted through cervix
dye injected
x-ray image taken
observe fallopian tubes
other tests for investigating fertilit
serum prolactin
TFTs
chlamydia screening
pelvic US for uterine problems
also - rubella immunity, cervical smear up to date
managing ovulation disorder
optimise body weight, healthy lifestyle, exercise
medication
laparoscopic ovarian drilling
medication for ovulation disorders
ovulation induction:
- clomiphene citrate
- gonadotrophins
managing sperm problems - very low count/no sperm
medication - gonadotrophins
surgical sperm retrieval - epididymis/testis
donor sperm - intrauterine insemination
ICSI - intracytoplasmic sperm injection
what is azoospermia
no sperm in the ejaculate
management of tubal problems
role of surgery is limited to mild tubal disease
IVF
management of endometriosis for infertility
ablation/resection of spots
adhesiolysis
cystectomy for endometrioma
uterine surgery for infertility
removal of polyp/fibroid
adhesiolysis for synechiae
management of unresolved infertility
IVF
human fertilisation and embryology authority
regulatory authority licensing inspections forms - registration, treatment, outcome register
what eggs are used in IVF
own eggs - gonadotropin induced superovulation
donor eggs
when are donor eggs used in IVF
used with increased age and poor ovarian reserve - poor quality eggs, ovarian failure, genetic cause
what sperm are used in IVF
partner
donor
partner sperm for IVF
fresh sample on day of egg collection
frozen sample (thawed) from surgical retrieval or fertility preservation
donor sperm for IVF - when are they used
single women same sex relationship azoospermia genetic cause infection - HIV, hep B/C
IVF process - 8 key steps
controlled ovarian stimulation follicular monitoring timing ovulation egg collection lab fertilisation - insemination/ICSI incubation/embryo development embryo transfer progesterone support
‘managament’ following embryo transfer
progesterone pessaries
normal activity
pregnancy test after 2wks
if +ve - scan at 7wks
risks of IVF
ovarian hyperstimualtion syndrome (OHSS)
multiple pregnancy
medication side effects
procedure related
long term effects of IVF
children born - no difference as per short term data
risk of ovarian cancer not confirmed
absolute risk to women and children low
IVF expansions
donor gametes fertility preservation - gamete/embryo cryopreservation ovarian tissue cryopreservation preimplantation genetic diagnosis assisted hatching in vitro maturation surrogacy
