Infertility Flashcards
What is the definition of infertility?
Failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse in the absence of known reason in a couple who have never conceived a child
What are the types of infertility?
Primary - couple has never conceived
Secondary - couple has had a previous pregnancy, including those that did not result in live birth
What factors increase the chance of conception?
Young paternal age
Healthy BMI
Non-smoker
Timing intercourse with ovulation
What blood tests are done to test for causes of infertility?
FSH and LH Oestadiol Mid-cycle progesterone on day 21 (7 days before end of cycle) TFT Infection screen - rubella, HIV, hepatitis B/C Prolactin testosterone Sex hormone binding globulin
What is a progesterone challenge test?
Progesterone is given, a bleed after a 5 day course confirms oestrogen levels are normal
What factors are assessed in a semi analysis?
Volume pH Density and concentration of sperm Motility Sperm progression and morphology
What are causes of male factor infertility?
Idiopathic Cystic fibrosis Vasectomy Congenital - cryptorchidism, chromosomal abnormalities Infections - mumps, STIS Endocrine causes Testicular tumours Sperm abnormalities
Why does cystic fibrosis cause infertility in males
CF causes obstruction or absence of the vas deferent bilaterally (congenital bilateral absence of vas deferens - CBAVD)
What are the blood results in obstructive causes of infertility in males?
Normal LH, FSH and testosterone
What is cryptorchidism?
One or both testes are undescended into the dependent part of the scrotal sac
What is the presentation of cryporchidism?
Testes cannot be palpated within the dependent part of the scrotal sac
May be found in the upper part of the scrotum, the inguinal canal, intra-abdominally or none of these places
Who is cryptorchism more common in?
Premature babies
Babies with low birth weigher or small for gestational age
What is Kleinefelter’s syndrome?
47 XXY
Genetical male with an extra X chromosome
What is the presentation of Kleinefelter’s syndrome?
Slight developmental delay Reduced facial fair Poor muscle tone Gynaecomastia at puberty Small firm testes
What do blood tests show in Kleinefelter’s syndrome?
High GnRH
Low testosterone
How is Kleinefelter’s syndrome diagnosed?
Karyotype
How can mumps cause infertility?
Mumps orchitis can cause reduced spermatogenesis and can cause obstructive infertility
Testicular swelling can damage seminiferous tubules and affect sperm production
What is the prognosis of infertility caused by mumps?
Shot-term - improves in the months after recovery
Which endocrine tumours can cause infertility?
Pituitary tumours Hypothalamous disorders Hypo and hyperthyroidism Diabetes Congenital adrenal hyperplasia Steroids abuse
What do blood tests show in pituitary and hypothalamus causes of infertility?
Low LH, FSH and testosterone
Why can both hypo and hyperthyroidism cause reduced fertility?
Hyper - decreased sexual function
Hypo - increased prolactin
How does congenital adrenal hyperplasia cause infertility in men?
Increased testosterone
What is globozoospermia?
Sperm abnormality where spermatozoa have rounded heads instead of oval, and no acrosome
Without this the sperm can’t fuse with the egg
What are the categories of female infertility?
Anovulatory infertility
Tubal factor infertility
What are hypothalamic causes of anovulatory infertility?
Anorexia, bulilia
Excess exercise
Idiopathic hypogonadotrophic hypogonadism
Kallman syndrome
What do blood tests show in anorexia, bulimia or excess exercise causing anovulatory infertility?
Low FSH and LH
Low oestradiol
What is idiopathic hypogonadotrophic hypogonadism?
Incomplete or absent puberty
Lack of GnRH production by the hypothalamus
What do blood tests show in idiopathic hypogonadotrophic hypogonadism?
Low FSH and LH
Low oestrogen
Negative progesterone test
What is Kallman syndrome?
Hypogonadotrophic hypogonadism causing incomplete or absent puberty and anosmia
How does hyperprolactinaemia cause anovulatory infertility?
Increased level of prolactin prevents ovulation
What are the clinical features of hyperprolactinaemia?
Amenorrhoea or oligomenorrhea
Galactorrhoea
What are causes of hyperprolactinaemia?
Prolactinoma
Dopamine antagonist drugs
What investigations are done for hyperprolactinaemia?
Pituitary function tests
MRI pituitary
Medication review
What is the management of hyperprolactinaemia?
Dopamine agonists: bromocriptine, cabergoline
Surgery to remove tumour
What is Sheehan’s syndrome?
Post-partum hypopituitarism
Can cause anovulation
How does PCOS cause infertility?
Overproduction of oestrogen means those with the condition do not release an ovum
In the long term the increased levels of testosterone can impair ovum quality
What do blood tests show in PCOS?
High LH
High free androgens
Impaired glucose tolerance
What is the management of infertility in PCOS?
Clomiphene +/- metformin
Ovarian diathermy and gonadotrophin induction
IVF
How does clomiphene work?
An anti-oestrogen
Helps to induce ovulation by increasing release of FSH/LH so first line for women trying to conceive
What is premature ovarian failure?
Ovaries stop producing oestrogen and healthy ova before age 40
What are causes of premature ovarian failure?
Idiopathic
Genetic disorders - Turner’s, fragile X
Chemotherapy or radiotherapy
Autoimmune response to ovarian tissue
What are symptoms of premature ovarian failure?
Hot flushes Night sweats Atrophic vaginitis Oligomenorrhea or amenorrrhoea Anovulation - infertility
What do investigations show in premature ovarian failure?
High FSH and LH
Low oestradiol
What is the management of premature ovarian failure?
HRI
How can tubal factors cause infertility?
A blockage can occur in one or both of the fallopian tubes, preventing the sperm from arching the ovum
Complete blockage or tubal scarring causing narrowing
What are infective causes of tubal factor infertility?
Pelvic inflammatory disease
Trans-peritoneal spread from e.g. appendicitis
Iatrogenic source of infection - eg. IUD, hysteroscopy
What are non-infective causes of tubal factor infertility?
Endometriosis
Salpingitis isthmica nodosa
Uterine polyps
Uterine fibroids
What is the management of endometriosis causing infertility?
Laparoscopic surgery ro remove endometrial growth, cysts and adhesions without damaging female reproductive organs
What is salpingitis isthmica nodes?
Nodular scarring of the fallopian tube due to inflammation
Development of irregular benign extensions of the tubal epithelium
Results in narrowing of tube
How can polyps cause infertility?
Can develop at the opening of the fallopian tubes, blocking them and preventing sperm reaching the ovum
Polyps that develop in the endometrium can interfere with the process of implantation
What are the options for assisted conception treatment?
Donor insemination
Intra-uterine insemination
In vitro fertilisation
Intra-cytoplasmic sperm injections
What are the indications for assisted conception treatment?
Couples with fertility issues where at least one partner does not have a biological child
Same sex couples
Preservation of fertility in patients undergoing cancer treatment or gender reassignment where fertility may be lost
To avoid transmission of BBV e.g. HIV
To allow pre-implantation diagnosis of certain inherited disorders
What are the criteria for assisted conception treatment?
Couple co-habiting in a stable relationship for minimum 2 years
Both parents non-smoking, no illegal substances, methadone free, no alcohol
BMI of female above 18.5 and below 30
Neither partner ever had sterilisation
Female up to date with smears, immunised against rubella and screens for BBVs
What is intra-uterine insemination?
Direct placement of the sperm inside the uterus
When is intra-uterine insemination possible?
Where sperm and semen are healthy, ovulation is taking place and there is no tubal disease
What are indications for intra-uterine insemination?
Sexual dysfunction
- Ejaculation disorders, erectile dysfunction, sexual pain disorders
Female same sex relationships - using donor sperm
Male same sex relationships - using surrogacy
What is the process of IVF?
- Down regulation - GnRH analogues to shut down natural menstrual cycle
- Ovarian stimulation - ovarian follicular development and oocyte maturation by gonadotrophin hormone injections, endometrial wall thickens
- Oocyte collection - un theatre under USS guidance, needle inserted trans-vaginally to collect oocytes
- Fertilisation - sperm placed in petri dish with oocyte where fertilisation takes place and zygote forms
What is the process of intra-cyclic sperm injection?
- Down regulation - GnRH analogues to shut down natural menstrual cycle
- Ovarian stimulation - ovarian follicular development and oocyte maturation by gonadotrophin hormone injections, endometrial wall thickens
- Oocyte collection - un theatre under USS guidance, needle inserted trans-vaginally to collect oocytes
- Fertilisation - one sperm immobilised and injected into the cytoplasm of the oocyte
When is intra-cyclic sperm injection preferred?
Low numbers of sperm
Reduced sperm motility
Abnormal sperm morphology
What are the indications for intra-cyclic sperm injection?
Severe male factor infertility
Previous failed fertilisation with IVF
Pre-implantation genetic diagnosis
What are the complications of assisted reproductive treatment?
Ovarian hyper-stimulation syndrome Multiple pregnancy Ectopic pregnancy Increased risk of miscarriage Surgical risk in oocyte collection
What is ovarian hyper-stimulation syndrome?
In response to ovarian stimulation in stage 2 of IVF and ICSI
Large numbers of growing follicles and high oestradiol can lead to release of inflammatory markers and vasoactive substances
This can cause fluid shift from blood vessels to third compartment and fluid buildup in the abdomen
If severe -thromboembolic disease and acute respiratory distress syndrome
What is the presentation of ovarian hyper-stimulation syndrome?
Bloating
Abdominal distension
Nausea and vomiting
In woman undergoing IVF
What is the management of ovarian hyper-stimulation syndrome before embryo transfer?
Elective freeze
Single embryo transfer
What is the management of ovarian hyper-stimulation syndrome after embryo transfer?
Monitor with USS and blood tests
Reduce thrombosis risk (fluids, TED stockings, frogmen)
Analgesia
