infertility Flashcards
definition of infertility
failure to achieve a clinical pregnancy after 12 months of more of regular unprotected sexual intercourse (in absence of known reason) in a couple who have never had a child (WHO definition)
what factors increase chances of conception
- Woman aged under 30 years
- Previous pregnancy
- Less than three years trying to conceive
- Intercourse occurring around ovulation
- Woman’s body mass index (BMI) 18.5 – 30m/kg2
- Both partners non-smokers
- Caffeine intake less than two cups of coffee daily
- No use of recreational drugs
what are some common causes of secondary infertility
- tubal disease
- fibroids
- endometriosis/adenomyosis
- weight related
- age related
gynaelogical conditions that cause anovulatory infertility
- anorexia, bulimia, excessive exercise
- hyperprolactinaemia, tumours, Sheehan syndrome
- PCOS, premature ovarian failure
other conditions that cause anovulatory infertility
- Systematic disorder: e.g. chronic renal failure.
- Endocrine disorder: e.g. testosterone secreting tumours, congenital adrenal hyperplasia, thyroid
- Drugs: e.g. depo-provera, explanon, OCP
clinical features of PCOS
obesity, hirsutism or acne, menstrual cycle abnormalities and infertility
endocrine features of PCOS
high free androgens, high LH, impaired glucose tolerance
diagnosis of PCOS
score 2 out of three:
- chronic anovulation
- polycystic ovaries
- hyperandrogenism (clinical or biochemical)
clinical features of premature ovarian failure
hot flushes, night sweats, atrophic vaginitis, amenorrhoea, infertility
endocrine features of premature ovarian failure
high FSH, high LH, low oestradiol
infective causes of tubal disease
- Pelvic inflammatory disease (chlamydia, gonorrhoea, other: anaerobes, syphilis, TB)
- transperitoneal spread: appendicitis, intra-abdominal abscess
- following procedure: IUCD insertion, hysteroscopy, HSG
non-infective causes of tubal disease
- endometriosis
- surgical (sterilisation, ectopic pregnancies)
- fibroids
- polyps
- congenital
- salpingitis isthmica nodosa
clinical features of hydrosalpinx
- abdominal/pelvic pain febrile
- vaginal discharge dyspareunia
- cervical excitation menorrhagia
- dysmenorrhoea
- infertility
- ectopic pregnancy
what is endometriosis
presence of endometrial glands outside uterine cavity
causes of endometriosis
Retrograde menstruation is most likely cause, altered immune function, abnormal cellular adhesion molecules, genetic
clinical features of endometriosis
dysmenorrhoea (classically before menstruation), dysparenuia, menorrhagia, painful defaecation, chronic pelvic pain, uterus may be fixed and retroverted, scan may show characteristic ‘chocolate’ cysts on ovary, infertility, asymptomatic
drugs that cause male infertility
- alcohol
- SSRI anti-depressants
- tobacco
- cocaine
- marijuana
- testosterone supplements
clinical features of non-obstructive male infertility
low testicular volume
reduced secondary sexual characteristics
vas deferens present
endocrine features of non-obstructive male infertility
High LH, FSH and low testosterone
clinical features of obstructive male infertility
normal testicular volume
normal secondary sexual characteristics
vas deferens may be absent
endocrine features of obstructive male infertility
Normal LH, FSH and testosterone
investigation of infertility
infertility history, gynaecology, andrology, sexual history, social history, PMH, PSH, POH
examination of female infertility
- BMI
- General examination, assessing body hair distribution, galactorrhoea
- Pelvic examination, assessing for uterine and ovarian abnormalities/tenderness/mobility
examination of male infertility
- BMI
- General examination
- Genital examination, assessing size/position testes, penile abnormalities, presence vas deferens, presence varicoceles
investigations for female infertility
- endocervical swab for chlamydia
- cervical smear if due
- blood for rubella immunity
- midluteal progesterone level (day 21 of 28 day cycle or 7 days prior to expected period in prolonged cycles), -progesterone > 30nmol/l suggestive ovulation
- Test of tubal patency: hysterosalpingiogram (HSG) /hycosy or laparoscopy
investigations for male infertility
- History (PMH, occupation, drugs, social, andrology)
- Examination (general and genitalia)
- Semen analysis: twice over 6 weeks apart
what are some vitamin supplements for infertility
- folic acid
- vitamin D
management of hypothalamic anovulation
- stabilise weight
- pulsatile GnRH
- gonadotrophin daily injections
- USS of ovarian response
how is ovulation inducted in PCOS
- clomifene citrate
- gonadotrophin daily injections
- laparoscopic ovarian diathermy
what can reproductive surgery be used for
- pelvic adhesions
- grade 2 endometriosis
- chocolate cysts in ovary
- tubal block
treatment for women with proximal tubal obstruction
- selective salpingography plus tubal catheterisation
- hysteroscopic tubal cannulation
how should submucosal fibroids be treated
hysteroscopically to improve conception rates
treatment of male infertility
Surgery to obstructed vas deferens (50% success following vasectomy)
Intrauterine insemination in mild disease
Intracytoplasmic sperm injection (ICSI)
Surgical sperm aspiration from epididymis or testicle combined with ICSI
Donor sperm insemination.
