Infertility Flashcards
Define infertility
Inability to conceive after regular sex for 12 months without contraception
What is the difference between primary & secondary infertility?
Primary have never conceived secondary have conceived but it didn’t result in a child (e.g. miscarriage/ectopic)
What is the length of a regular cycle?
28-35 days
Define oligomenorrhoea
cycles >35days
Define primary and secondary amenorrhoea
Primary never have had periods and secondary have had them and then they stopped
What do ovulatory predictor kits detect and why are they not 100% reliable?
Detects LH surge (24-36hr before ovulation), not 100% reliable only 97% because of how people might excrete their LH
How is ovulation assessed and how is this adjusted for cycle length?
Midluteal serum progesterone, adjust by doing it about a week before end of cycle
What are initial investigations in primary care for infertility for females? (5)
Day 21 progesterone to establish ovulation (or adjusted to cycle day) TSH Rubella immunity Chlamydia screen Ensure cervical smear up to date
What affect does rubella have in foetus if mother is infected during pregnancy?
Affects neurological development
If cycle lasts longer than 42 days or if amenorrhoeic, what investigations are carried out?
Follicular phase bloods: LH,FSH, E2
Testosterone, Sex Hormone Binding Globulin (SHBG), FAI (free antigen index) - tells you how much available testosterone in system
Prolactin
What are the 3 important parameters in diagnostic semen analysis?
Need to be:
16million sperm per ml
30% progressive motility
At least 4% to be normal morphologically
What is azoospermia
No sperm in ejaculate
Asthenozoospermia
poor sperm swimming - low progressive motility
oligozoospermia
concentration of sperm low
teratozoospermia
morphologically normal sperm below reference limit
List 6 possible abnormal findings from ultrasound of female
congenital uterine abnormality fibroids endometrial polyp hydrosaplinx PCOS Ovarian cyst (simple, dermoid, cancer, endometrioma)
What is hydrosaplinx?
fluid in fallopian tube usually due to blockage
How is tubal patency test done & when is it used?
Hysterosaplingogram (HSG) - xray on uterus with dye
Used if no known risk factors/pelvic pathology and laparoscopy contraindicated e.g. obesity, previous pelvic surgery, Crohn’s disease
What is surgical option for tubal patency testing?
laparoscopy and hydrotubation (HTB )
When would you do HTB?
possible tubal/pelvic disease e.g. PID
Known previous pathology e.g. ectopic pregnancy, ruptured appendix, endometriosis
History suggestive of pathology e.g. dysmenorrhoea, dyspareunia
Previously abnormal HSG
When is hysteroscopy preformed?
When suspected or known endometrial pathology e.g. uterine septum, adhesions, polyp
What are some lifestyle advice changes for management of infertility?
stop smoking!! BMI 18.5-30 Reduce/stop alcohol moderate caffeine stop recreation drugs/methadone folic acid
Why is it recommended to take folic acid up to 3 months preconception and for first 3 months of pregnancy?
Reduce chance of neural tube defects in foetus
What is the most common cause of ovulation problems?
Polycystic ovarian syndrome
Outline Rotterdam diagnostic criteria for PCOS.
Need 2/3 of:
- oligo/amenorrhoea
- polycystic ovaries (12/more 2-9mm follicles, increased ovarian volume >10ml and unilateral/bilateral)
- Clinical and/or biochemical signs of hyperandrogenism (acne, hirsutism)
What is first, second and third line for ovulation induction?
Clomifene citrate/letrozole
Gonadotrophin injections
Laparoscopic ovarian diathermy
What is clomifene/letrozole?
anti-oestrogen property so boosts FSH signal from pituitary
What are risks of gonadotrophin injections?
multiple pregnancy, overstimulation
What is 3rd line for ovulation induction?
Laparoscopic ovarian diathermy
All 3 ovulation induction treatment options have approx. 80% ovulation rate. What is best one for getting single child pregnancy?
ovarian diathermy
15-20% of patients do not ovulate on clomifene. What are some options for clomifene resitant?
weight loss,
letrozole or
adjuvant metformin because it improves insulin resistance, reduction in androgen production and increase in SHBG (restoration of menstruation and ovulation, may increase pregnancy rate, improves sensitivity to clomifene)
If male abnormal semen analysis, what investigations should you do?
Male exam (volume of testicle exam) Check LH, FSH, testosterone, prolactin Karyotype (e.g. Klinefelters), Cystic Fibrosis mutation, Y microdeletions (spermatogenesis coding gene)
List 3 types of treatment assisted reproduction technology (ART)
IUI: intrauterine insemination +/- superovulation
IVF: in vitro fertisialtion
ICSI: intracytoplasmic sperm injection
There is limited/no treatment for tubal disease. What are options?
If small proximal tube occlusion cannulation using guidewire or microcatheter but otherwise IVF (Hydrosalpinx reduces IVF success by 50%)
What are the criteria for art eligibility? (8)
stable relationship 2y (incl. same sex) female age <40yrs (<42yrs) Female BMI 18.5-30 non-smokers (at least 3/12 pre-treatment) no biological child no illegal/abusive substances neither partner to havebeen sterilised duration unexplained infertility 2years
If they meet ART criteria how many goes of IVF do they get? Is eligibility checked each time?
3 times, yes eligibility checked each time
What is treatment schedule for IVF
Day 21: buserelin for 2-3 weeks
baseline scan
FSH/hMG injections for 8-9 days
Action scan
stop everything if ready (can see follicles)
hCG single injection (acts like LH to simulate LH surge)
egg recovery 36hrs later
crinone gel daily to mimic progesterone surge
Embryos cultured & then transfer
What percent of couples are affected by infertility?
15%
What is chance couple with conceive in second year of trying?
50%
How frequent should sexual intercourse be when trying to conceive?
2-3 times per week
What is most common reason for requiring IVF/ICSI treatment?
abnormal sperm - male factor infertility
List 3 common complications of IVF treatment.
multiple pregnancies
hyperstimulation
Procedure side effects: bleeding & infection
According to UK law, how many embryos can be transferred following IVF?
3
By 24 months approximately what percentage of couples will have conceived?
94%
If patient has had a child in a previous relationship but in current relationship they have not had a child. Is that still primary infertility?
Yes
Infertility causes are approximately __ male, __ female and __ unexplained.
1/3, 1/3, 25%
What is most important factor in fertility?
Woman’s age - sharp decline from 35 onwards and miscarriage risk goes up
What are 3 basic concepts when approaching infertility?
Ovulating? Tubal blockage? Sperm?
Luteal phase is constant whereas follicular phase is variable. This means people with longer period have longer ___ phase.
Follicular phase
Transvaginal ultrasound scans are routine part of infertility consultation, true/false?
True
One faulty cystic fibrosis gene can result in absence of one or both vas deferns. True/false?
True
Abnormal semen analysis results are usually treatable. True/false?
False - >50% unexplained causes and usually few treatment options except ART
Reversal of sterilisation is available on the NHS. True/false?
False - it is not available
When is intrauterine insemination (IUI) a good option? (2)
Same sex couple,
issues with sexual function e.g. dyspareunia, erectile dysfunction
When is ICSI a good option? (1)
Male factor infertility
When can woman be considered for ART when between age 40-42?
If they’ve never had treatment and have a reasonable prognosis
How many cycles of treatment can you get if you are eligible for ART?
3 cycles
What is buserelin?
Downregulation nasal spray, is a GnRH agonist so pituitary function is suppressed
What is current live take home baby rate per cycle IVF treatment?
Approx. 30%
1 in __ have fertility assessment in UK?
1 in 6
When a man has had a vasectomy, what is the best fertility treatment?
Surgical sperm retrieval and ICSI
