Infertility Flashcards
What is infertility?
Inability to conceive after 12 months regular intercourse without contraceotion
What is primary infertility?
Couple hasn’t conceived before
Secondary infertility?
Couple have conceived together in the past (even if it hasn’t resulted in a live birth)
Definition of oligomenorrhoea?
Cycles >35 days
Amennorhoea?
Absent menstruation
What triggers menstruation?
LH surge
What follows ovulation?
Progesterone peaks
How do you confirm ovulation?
Midluteal serum progesterone (>30nmol/L)
Day 21 (28 cycle)
Adjust for cycle length
Investigations if amenorrhoeic/cycle longer than 42 days?
- Follicular phase bloods- LH, FSH, E2
- Testosterone, SHBG, FAI
- Prolactin
- Diagnostic semen analysis
Semen analysis looks at?
Sperm conc- 16 million per ml
Progressive motility - 30%
Sperm morphology - 4% normal
What should sperm conc be (units)?
16 million per ml
Initial info to get at infertility consultation?
- Patients seen as couple
- Establish length of relationship
- length of time trying to get pregnant
What to ask about female in infertility consultation?
History
Exam/USS: pelvic anatomy- uterus & ovaries, transvaginal US
Investigation
What to look into for the male in an infertility consultation?
History
Diagnostic semen analysis
Examination
Investigations
Abnormal findings in infertility investigations?
- Congenital uterine abnormalities
- Fibroids
- Endometrial polyp
- Hydrosalpinx
- PCOS
- Ovarian cyst
- Tubal patency
Types of ovarian cysts?
Simple
Dermoid
Cancer
Endometrioma
Investigations of tubal patency?
Hysterosalpingogram (HSG)
Diagnostic laparoscopy and hydrotubation
When would you do a diagnostic laparoscopy?
Possible tubal/pelvic disease
Known previous pathology
History suggestive of pathology
Prev abnormal HSG
When is a hysteroscopy performed?
-Cases where sus or known endometrial pathology (uterine septum, adhesions, polyp)
Lifestyle advice for infertility?
- Stop smoking
- BMI: 18.5-30
- Reduce/lessen alcohol consumption
- Moderate caffeine
- Stop recreational drugs
- Folic acid
- Stop smoking
Most common reason for ovulatory problems?
Polycystic ovarian syndrome (PCOS)
What criteria do you use for PCOS?
Revised Rotterdam diagnostic criteria
Revised Rotterdam diagnostic criteria?
2 of:
- Oligo/menorrhoea
- Polycystic ovaries
- Clinical and/or biochem signs of hyperandrogenism (acne/hirsutism)
Scan appearance of polycystic ovaries?
12/more 2-9mm follicles
Increased ovarian volume >10ml
Unilateral/bilateral
1st line for ovulation induction?
Clomifene citrate
- 50-100-150 mg tab, days 2-6
- 70-80% ovulate, 30-40% conceive
Alternatively Letrozole (Tamoxifen)
Other methods of ovarian induction?
Gonadotrophin injections
Laparoscopic ovarian diathermy
Details about gonadotrophin injections?
- Recombinant FS
- 80% ovulate, 60-70% conceive
- Risks: multiple pregnancy, overstimulation
Details about laparoscopic ovarian diathermy?
- 80% ovulate, risk ovarian destruction
- Mainly singleton pregnancies
Whats the downside of clomifene?
CLOMIFENE RESISTANCE
What’s the craic with clomiphene resistance?
15-20% of ptnts don’t ovulate on it
- Wt loss
- Letrozole
- Adjuvant metformin
Approach to abnormal semen parameters?
- Examination
- Check LH, FSH, Testosterine, prolactin
- Karyotype, CF mutation
- 50% unexplained causes
What does treatment mainly include for abnormal semen parameters?
-ART (assisted repro technology)
Intrauterine insemination (iui)
IVF
Intracytoplasmic sperm injection
Treatment for blocked fallopian tubes?
Generally no treatment
-Could try IVF, hydrosalpinx reduces IVF success by 50%
-Cannulation using guidewire or microcatheter
Proximal tube occlusion
-Reversal of sterilisation- not on NHS
Eligibility criteria for assisted reproduction technology?
- Stable relationship (2y + same sex is g)
- Female age <40y
- Female BMI (18.5-30)
- Non smokers (at least 3/12 before treatment)
- No biological child
- No illegal substances/abuse substance
- Neither sterilized
- Duration unexplained infertility 2y
- Up to 3 cycles treatment
Biggest factor influencing infertility?
Female age
All terms meaning type 1 ovulation disorder?
Hypogonadal hypogonadism
Hypothalamic pituitary failure
The problem in type 1 ovulation disorder?
Problem with not producing enough GnRH or dysregulation in pulsatility
Hormones levels in hypogonadal hypogonadism?
Low LH
Low FSH
Causes of type 1 ovulation disorder?
- Stress
- XSive exercise
- Low BMI
- Brain tumours
- Head trauma
- Kallman syndrome
- Drugs (steroids, opiates)
What will be present in hypothalamic pituitary failure?
Amenorrhoea
Treatment of hypogonadal hypogonadism?
- Improvement to modifiable factors
- Ultimate treatment: pulsatile GnRH pump or FSH and LH daily injections
Another term for type 2 ovulation disorder?
Normogonadotrophic anovulation
Main cause of T2 ovulation disorder?
Polycystic ovarian syndrome
Hormone levels in type 2 ovulation disorder?
Normal GnRH
Normal FSH
Potential XS LH
What charcterizes type 2 ovulation disorder?
Multiple small cysts within the ovary and by XS ovarian androgen production
What is T2 ovulation disorder assoc with?
Obesity Hyperinsulinaemia Insulin resistance Increased risk of T2DM HT Hyperlipidaemia Increased CVS risk
Diagnostic criteria of normogonadotrophic anovulation?
2 or more:
-Clinical and/or biochem evidence of hyperandrogenism, oligo/anovulation, Polycystic ovaries on US
Treatment of T2 ovulation disorder?
Wt loss
Treating acne
Treating hirsutism
Fertility treatment: involves ovulation induction
1st line fertility treatment for normogonadotrophic anovulation?
Clomifene used on days 2-6 of cycle
What may become 1st line ovulation induction?
Letrozole (as it requires less monitoring)
2nd line fertility treatment?
Gonadotrophin injections with recombinant FSH
However this risks multiple pregnancy and overstimulation
Risks of gonadotrophin injection?
Overstimulation and multiple pregnancy
3rd line infertility treatment?
Laparoscopic ovarian diathermy
Isn’t risk of multiple pregnancies but procedure risks ovarian destruction
Terms for type 3 ovulation disorder?
Hypergonadotropic hypogonadism
Premature ovarian failure
What is characteristic of Type 3 ovulation disorder?
Premature menopause
Ovarian failure before age 40
Amenorrhoea
Hormone levels in type 3?
LH raised
FSH raised
Oestrogens decreased
Causes of type 3 ovulation disorder?
- Turner syndrome
- Other genetic conditions
- AI failure
- Surgery
- Chemo/radio therapy
What can a person with T3 ovulation disorder not do?
Be stimulated to produce eggs
What should people with premature ovarian failure be on?
Combined HRT
Infertility treatment if peri-menopausal?
-Egg donor and then hormonal treatment to help them maintain a pregnancy
Type 4 ovarian disorder other term?
Hyperprolactinaemia
Whats happening in T4 ovarian disorder?
Person has elevated serum prolactin and low/normal FSH and LH
Frequently due to pituitary adenoma
Azoospermia?
No sperm in ejaculate
Asthenozoospermia?
% of progressive motile sperm is below reference limit
Oligozoospermia?
Total number/concentration of sperm below reference limit
Teratozoospermia?
% of morphologically normal sperm below reference limit
Initial GP investigations in women for infertility?
Day 21 progesterone to establish ovulation
TSH
Rubella immunity checked
Chlamydia screen
-Ensure smear up to date
-If amenorrhoeic or cycle lasts longer than 42 days they should have follicular phase bloods (LH, FSH, E2), testosterone, SHBG, FAI and prolactin checked
Initial GP investigations in men?
Diagnostic semen analysis
If there are abormal semen parameters he male should be examined as well as LH, FSH, testosterone and checked for genetic causes
