Infertility Flashcards
What is the likelihood that a couple will conceive within a year of regular unprotected sex?
85% will conceive within a year of regular unprotected sex. 1 in 7 couples will struggle to conceive naturally.
When should a couple be referred for investigations for infertility?
Investigation and referral for infertility should be initiated after the couple has been trying to conceive without success for 12 months. This can be reduced to 6 months if the woman is older than 35, as her ovarian stores are likely to be already reduced and time is more precious.
What are the causes of infertility?
- Sperm problems (30%)
- Ovulation problems (25%)
- Tubal problems (15%)
- Uterine problems (10%)
- Unexplained (20%)
40% of infertile couples have a mix of male and female causes.
What lifestyle advice is given to couples trying to conceive?
There is some general lifestyle advice for couples trying to get pregnant:
- The woman should be taking 400mcg folic acid daily
- Aim for a healthy BMI
- Avoid smoking and drinking excessive alcohol
- Reduce stress as this may negatively affect libido and the relationship
- Aim for intercourse every 2-3 days
- Avoid timing intercourse
Timed intercourse to coincide with ovulation is not necessary or recommended as it can lead to increased stress and pressure in the relationship.
What initial ivestigations should be ordered in the community for infertility?
Initial investigations, often performed in primary care:
- Body mass index (BMI) (low could indicate anovulation, high could indicate PCOS)
- Chlamydia screening
- Semen analysis
- Female hormonal testing
- Rubella immunity in the mother
Briefly describe female hormone testing
Female hormone testing involves:
- Serum LH and FSH on day 2 to 5 of the cycle
- Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle).
- Anti-Mullerian hormone
- Thyroid function tests when symptoms are suggestive
- Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea
What does a high FSH indicate?
High FSH suggests poor ovarian reserve (the number of follicles that the woman has left in her ovaries). The pituitary gland is producing extra FSH in an attempt to stimulate follicular development.
What does high LH indicate?
High LH may suggest polycystic ovarian syndrome (PCOS).
What does a rise in progesterone on day 21 indicate?
A rise in progesterone on day 21 indicates that ovulation has occurred, and the corpus luteum has formed and started secreting progesterone.
What does anti-Mullerian hormone indicate?
Anti-Mullerian hormone can be measured at any time during the cycle and is the most accurate marker of ovarian reserve. It is released by the granulosa cells in the follicles and falls as the eggs are depleted. A high level indicates a good ovarian reserve.
What ivestigations should ordered in secondary care for infertility?
Further investigations, often performed in secondary care:
- Ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus
- Hysterosalpingogram to look at the patency of the fallopian tubes
- Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis
Briefly describe a hysterosalpingogram
A hysterosalpingogram is a type of scan used to assess the shape of the uterus and the patency of the fallopian tubes. Not only does it help with diagnosis, but it also has therapeutic benefit. It seems to increase the rate of conception without any other intervention. Tubal cannulation under xray guidance can be performed during the procedure to open up the tubes.
A small tube is inserted into the cervix. A contrast medium is injected through the tube and fills the uterine cavity and fallopian tubes. Xray images are taken, and the contrast shows up on the xray giving an outline of the uterus and tubes. If the dye does not fill one of the tubes, this will be seen on an xray and suggests a tubal obstruction.
There is a risk of infection with the procedure, and often antibiotics are given prophylactically for patients with dilated tubes or a history of pelvic infection. Screening for chlamydia and gonorrhoea should be done before the procedure.
Briefly describe a laparoscopy and dye test
The patient is admitted for laparoscopy. During the procedure, dye is injected into the uterus and should be seen entering the fallopian tubes and spilling out at the ends of the tubes. This will not be seen when there is tubal obstruction. During laparoscopy, the surgeon can also assess for endometriosis or pelvic adhesions and treat these.
How can infertility due to anovulation be treated?
The options when anovulation is the cause of infertility include:
- Weight loss for overweight patients with PCOS can restore ovulation
- Clomifene may be used to stimulate ovulation
- Letrozole may be used instead of clomifene to stimulate ovulation (aromatase inhibitor with anti-oestrogen effects)
- Gonadotropins may be used to stimulate ovulation in women resistant to clomifene
- Ovarian drilling may be used in polycystic ovarian syndrome
- Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)
Briefly describe the use of clomifene
Clomifene is an anti-oestrogen (a selective oestrogen receptor modulator). It is given on days 2 to 6 of the menstrual cycle. It stops the negative feedback of oestrogen on the hypothalamus, resulting in a greater release of GnRH and subsequently FSH and LH.
