Infertility Flashcards
What percentage of couples will conceive within a year of regular unprotected sex?
<40 woman
85%
When should you start investigations for infertility?
12 months of regular unprotected
Intercourse
6 months if woman >35
Oocytes at puberty and menopause
400,000 at puberty
<1000 at menopause
Causes of infertility
Sperm problems (30%) Ovulation problems (25%) Tubal problems (15%) Uterine problems (10%)
General lifestyle advice for couples trying to get pregnant
400mcg folic acid daily
Aim for healthy BMI
Avoid smoking and drinking excessive alcohol
Reduce stress as this may negatively affect libido
Intercourse every 2-3 days
Avoid timing intercourse
Causes of anovulation
PCOS
Weight-related <18, >30
Ovarian failure
Hyperprolactinaemia
Tubal disease causing infertility
PID
Pelvic surgery
Endometriosis
Female history for infertility
Age Duration, type of infertility Menstrual cycle Tubal surgery/ PID Menorrhagia, dysmenorrhea, pelvic pain Pelvic surgery
Examination of female factor infertility
BMI Body hair distribution Galactorrhea Secondary sexual characteristics Bimanual pelvic examination Adhesion or masses
When should LH, FSH be measured?
Day 2
Follicular phase
When should progesterone be measured?
D12
Investigations for female factor infertility
Follicular phase Luteal phase Rubella states Tests of tubal patency: hysterosapingography Chlamydia
Male history for infertility
General health Alcohol/smoking Previous surgery Previous infections Sexual dysfunction
Male factor infertility examination
Examination not essential Scrotum- varicocele Testicular size Testicular position: torsion Prostate for chronic infection
Semen analysis
- Semen analysis x2 (3 months)
- Semen volume 1.5ml or more
- PH 7.2 or more
- Sperm concentration: 15million/ ml
- Total number: >39/ ejaculate
- Total motility: 40% or more motile, 32% or more with progressive motility
- Vitality: 58% or more live spermatozoa
- Sperm morphology: 4% or more
- High scrotal temperature, drinking and smoking can affect so repeat after 3 months/ correcting factors
Female hormone testing
LH/FSH D2-5 Progesterone D21 Anti-mullerian hormone TFT Prolactin
High FSH
Poor ovarian reserve
High LH
PCOS
High progesterone day 21
Indicates ovulation has occurred
Corpus luteum formed
Most accurate marker of ovarian reserve
Anti-Mullerian hormone
Most accurate marker of ovarian reserve
High level, good ovarian reserve
Management of anovulation
Clomifene Letrozole Gonadotropin Ovarian drilling Metformin Dopamine agonists for hyperprolactinaemia
Management of tubal factors
Tubal cannulation during a hysterosalpingogram
Laparoscopy to remove adhesions or endometriosis
IVF
Management of uterine factors
Surgery may be used to correct polyps, adhesions or structural abnormalities affecting fertility
Management of sperm problems
Surgical sperm retrieval Blockage along vas deferens Intra-cytoplasmic sperm injection Donor insemination with sperm from a donor is another option for male factor infertility IVF
Male semen sample instructions
Abstain from ejaculation for 3-7 days
Avoid hot baths, sauna and tights underwear
Attempt to catch the full sample
Deliver the sample to the lab within 1 hour of ejaculation
Keep sample warm
Lifestyle factors affecting quality and quantity of sperm
Hot baths Tight underwear Smoking Alcohol Raised BMI Caffeine
Oligospermia
<15million
Pre-testicular causes
Testosterone
HPG axis
Pituitary gland/ hypothalamus
Stress, chronic conditions, hyperprolactinaemia
Kallman syndrome
Testicular causes
Mumps Undescended testes Trauma Radiotherapy Chemotherapy Cancer
Genetic or congenital disorders that result in defective or absent sperm produciton
Klinefelter’s syndrome
Y chromosome deletions
Sertoli cell-only syndrome
Anorchia
Post-testicular causes
Damage to testicular or vas deferens from trauma, surgery or cancer Ejaculatory duct obstruction Retrograde ejaculation Scarring from epididymitis Absence of vas deferens Young’s syndrome
Investigations for male factor infertility
Hormonal analysis Genetic testing Transrectal ultrasound or MRI Vasography Testicular biopsy
Management of male factor infertility
Surgical sperm retrieval where is obstruction
Surgical correction of an obstruction in vas deferens
Intra-uterine insemination
Intracytoplasmic sperm injection
Donor insemination
IVF attempt success
25-30%
IVF complications
Failure
Multiple pregnancy
Ectopic pregnancy
Ovarian hyper stimulation syndrome
Risk factors for ovarian hyper stimulation syndrome
Younger age Lower BMI Raised anti-Mullerian hormone Higher antral follicle count PCOS Raised oestrogen levels during ovarian stimulation
Management of ovarian hyper stimulation syndrome
Oral fluids Monitor urine output LMWH Ascitic fluid removal IV colloids
