infertility Flashcards

1
Q

human fertility compared to other mammals

A

inefficient reproductive system

conception per cycle - 20% at peak age, declines with age

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2
Q

natural expectation of pregnancy

A

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

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3
Q

why does female fertility decline

A

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

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4
Q

can we predict decline in fertility?

A

no

at the moment we can only plan ahead and use fertility tests (can’t determine if a women will get pregnant)

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5
Q

4 stages of conception

A

ovulation
sperm production
fertilisation
implantation

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6
Q

what does normal conception rely on

A
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
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7
Q

lifestyle factors affecting conception

A
age 
BMI
smoking 
alcohol 
recreational drug use
stress
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8
Q

clinical definition of infertility

A

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

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9
Q

epidemiological definition of infertility

A

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)

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10
Q

demographic definition of infertility

A

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

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11
Q

global infertility trends

A

10% of woman affected globally, likely underestimated (based on demographic definition)

1/7 couples in western world, 1/4 couples in developing countries affected

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12
Q

difficulties with estimating prevalence of infertility

A

main challenge in getting true estimates is inconsistency in definition used to calculate prevalence

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13
Q

when to refer

A

no conception after 1yr of regular unprotected intercourse

referral earlier if:

  • age >35
  • known cause for infertility
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14
Q

types of infertility

A

1y - never managed to have pregnancy before/never fathered a child

2y - have had a pregnancy before/fathered a child but cannot manage again

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15
Q

causes of infertility

A
male - 30%
female - 30%
combined - 10%
unexplained - 25%
other - 5%
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16
Q

female infertility factors

A
ovulatory dysfunction 35%
tubal factor 30%
diminishing ovarian reserve 20%
endometriosis - 10%
uterine factor 5%
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17
Q

male infertility factors

A

hormone production
blockage of sperm transport
sperm production problems
erection and ejaculation problems

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18
Q

why may there be blockage of sperm transport

A

infection
prostate related problems
absence of vas deferens
vasectomy

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19
Q

why may there be issues with sperm production

A
genetic
undescended testes
infection
torsion
varicocele
drugs 
radiation damage 
sperm antibodies
heat
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20
Q

why may there be erection and ejaculation problems

A
prostate surgery 
damage to nerves
ejaculation problems 
timing of intercourse
medication
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21
Q

investigating infertility

A

are eggs available
are sperm available
can they meet
any other factor

22
Q

investigating infertility - egg availability

A
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

23
Q

investigating infertility - is ovulation happening

A

used by couples:

  • natural methods - BBT, cervical mucus
  • LH ovulation kits
  • ovulation calender

used to investigate:
- D21 serum progesterone

24
Q

natural ovulation detection - basal body temperature

A

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

25
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
26
LH kits
measures peak of LH uses urine to measure LH surge - fertile
27
ovulation diagnosis
progesterone levels taken at appropriate time - day 21 only if 28/30 day cycle levels >20nmol/L show satisfactory ovulation
28
investigating infertility - sperm availability
semen analysis
29
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% ```
30
investigating infertility - can egg and sperm meet
intercourse - any difficulties, female or male | patent fallopian tubes
31
how to check fallopian tube patency
if no pelvic infection/gynae problem previously - hysterosalpingogram (HSG) if any of above - laparoscopic dye test
32
HSG - what is done
small catheter inserted through cervix dye injected x-ray image taken observe fallopian tubes
33
other tests for investigating fertilit
serum prolactin TFTs chlamydia screening pelvic US for uterine problems also - rubella immunity, cervical smear up to date
34
managing ovulation disorder
optimise body weight, healthy lifestyle, exercise medication laparoscopic ovarian drilling
35
medication for ovulation disorders
ovulation induction: - clomiphene citrate - gonadotrophins
36
managing sperm problems - very low count/no sperm
medication - gonadotrophins surgical sperm retrieval - epididymis/testis donor sperm - intrauterine insemination ICSI - intracytoplasmic sperm injection
37
what is azoospermia
no sperm in the ejaculate
38
management of tubal problems
role of surgery is limited to mild tubal disease IVF
39
management of endometriosis for infertility
ablation/resection of spots adhesiolysis cystectomy for endometrioma
40
uterine surgery for infertility
removal of polyp/fibroid | adhesiolysis for synechiae
41
management of unresolved infertility
IVF
42
human fertilisation and embryology authority
``` regulatory authority licensing inspections forms - registration, treatment, outcome register ```
43
what eggs are used in IVF
own eggs - gonadotropin induced superovulation donor eggs
44
when are donor eggs used in IVF
used with increased age and poor ovarian reserve - poor quality eggs, ovarian failure, genetic cause
45
what sperm are used in IVF
partner | donor
46
partner sperm for IVF
fresh sample on day of egg collection frozen sample (thawed) from surgical retrieval or fertility preservation
47
donor sperm for IVF - when are they used
``` single women same sex relationship azoospermia genetic cause infection - HIV, hep B/C ```
48
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 ```
49
'managament' following embryo transfer
progesterone pessaries normal activity pregnancy test after 2wks if +ve - scan at 7wks
50
risks of IVF
ovarian hyperstimualtion syndrome (OHSS) multiple pregnancy medication side effects procedure related
51
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
52
IVF expansions
``` donor gametes fertility preservation - gamete/embryo cryopreservation ovarian tissue cryopreservation preimplantation genetic diagnosis assisted hatching in vitro maturation surrogacy ```