Infertility Flashcards
When should a referral for infertility be initiated
After the couple has been trying to conceive without success for 12 months.
Can be reduced to 6 months if the woman is older than 35
Causes of infertility
Sperm problems Ovulation problems Tubal problems Uterine problems Unexplained
General advice for infertility
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
Timing intercourse to coincide with ovulation is not necessary or recommended as it can lead to increased stress and pressure in the relationship
Investigations for infertility
BMI
- low could indicate anovulation
- high could indicate PCOS)
Chlamydia screening
Semen analysis
Female hormonal testing
Rubella immunity in the mother
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 if suggestive
Prolactin
High FSH
Suggests poor ovarian reserve (the number of follicles that the woman has left in her ovaries)
High LH
Can indicated PCOS
Anti-Mullerian hormone
Can be measured at any time during the cycle and is the most accurate marker of ovarian reserve
Investigations for infertility performed in secondary care
Ultrasound pelvis - polycystic ovaries or any structural abnormalities in the uterus
Hysterosalpingogram - patency of the fallopian tubes
Laparoscopy and dye test - patency of the fallopian tubes, adhesions and endometriosis
Tubal cannulation
Under xray guidance
Performed during the hysterosalpingogram to open up the tubes
Risks of a hysterosalpingogram and how it’s minimised
Risk of infection - prophylactic antibiotics
Screening for chlamydia and gonorrhoea should be done before the procedure
Management of anovulation
Weight loss for overweight patients
Clomifene - stimulate ovulation
Letrozole instead of clomifene to stimulate ovulation
Gonadotropins - used to stimulate ovulation in women resistant to clomifene
Ovarian drilling - used in polycystic ovarian syndrome
Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)
Letrozole mechanism of action
Aromatase inhibitor with anti-oestrogen effects
Clomifene
Selective oestrogen receptor modulator (SERM)
Given on days 2 to 6 of the menstrual cycle
Stops the negative feedback of oestrogen on the hypothalamus, resulting in a greater release of GnRH and subsequently FSH and LH
Ovarian drilling
Laparoscopic surgery
Surgeon punctures multiple holes in the ovaries using diathermy or laser therapy.
Improve the hormonal profile and result in regular ovulation and fertility
Management of Tubal Factors
Tubal cannulation during a hysterosalpingogram
Laparoscopy to remove adhesions or endometriosis
In vitro fertilisation (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
Surgical correction
Intrauterine insemination
Intracytoplasmic sperm injection (ICSI)
Donor insemination
Donor insemination
Sperm from a donor used to inseminate woman
Surgical sperm retrieval
When there is a blockage somewhere along the vas deferens preventing sperm from reaching the ejaculated semen
A needle and syringe is used to collect sperm directly from the epididymis through the scrotum
Surgical correction of sperm problems
Surgically correct vas deferens occlusion
Intra-uterine insemination
Collecting and separating out high-quality sperm
Injecting them directly into the uterus
Intracytoplasmic sperm injection
Involves injecting sperm directly into the cytoplasm of an egg
These fertilised eggs become embryos, and are injected into the uterus of the woman.
When is intracytoplasmic sperm injection useful
Useful when there are significant motility issues, a very low sperm count and other issues with the sperm
