Infertility Flashcards
When should investigation and referral be done 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 ovarian stores are likely to be reduced and time is 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 are some general advice for couples trying to get pregnant?
- woman should be taking 400mcg folic acid daily
- aim for a healthy BMI
- avoid smoking and drinking ecessive alcohol
- reduce stress as may negatively affect libido and relationship
- aim for intercourse every 2-3 days
- avoid timing intercourse
timed intercourse to coincide with ovulation is not reccomended as it just increases stress and pressure in relationship
What are the initial investigations for infertility?
- BMI (low could indicate anovulation, high could indicate PCOS)
- chlamydia screening
- semen analysis
- female hormonal testing
- rubella immunity in the mother
What does female hormone testing involve?
- serum LH and FSH on day 2-5 of cycle
- serum progesterone on day 21 of cycle ( or 7 days before end of cycle)
- anti-mullerian hormone
- TFTs
- prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea
What would high FSH suggest?
-poor ovarian reserve (number of follicles that women has left in ovaries)
What would high LH suggest?
-polycystic ovarian syndrome
What would high progesterone on day 21 suggest?
-ovulation has occured and the corpus luteum has formed and started secreting progesterone
Why is Anti-mullerian hormone measured?
- can be measured at any time in the cycle and is the most accurate marker of ovarian reserve
- it is released by granulosa cells in the follicles and falls as the eggs are depleted.
- high level indicates a good ovarian reserve
What are the further investigation for infertility, often performed in secondary care?
- pelvic US –> to look for polycystic ovaries or any structural abnormalities in the uterus
- hysterosalpinogram –> 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
What is a hysterosalpingogram?
- a type of scan used to assess the shape of the uterus and the patency of fallopian tubes
- helps with diagnosis and has therapeutic benefit
- increases rate of conception
- tubal cannulation under xray guidance can be performed during this to open up tubes
How does a hysterosalpingogram work?
- small tube is inserted into cervix and a contrast medium is injected through the tube and fills the uterine cavity and fallopian tubes
- x-ray images are taken with contrast showing up outlining the uterus and tubes
- if contrast does not fill a tube, it suggests tubul obstruction
- as risk of infection with procedure, antibiotics are given prophylactically
What should be done before a hysterosalpingogram?
-screening for chlamydia and gonorrhoea
What does a laparoscopy and dye test involve?
- pt admitted for laparoscopy, during 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 me seen if there is tubal obstruction
- during laparoscopy, surgeon can also assess for endometriosis or pelvic adhesions and treat these
What are the management options when anovulation is the cause of infertility?
- weight loss for overweight pts with PCOS
- clomifene may be used to stimulate ovulation
- letrozole (aromatase inhibitor) may be used instead of clomifene
- gonadotropins may be used to stimulate ovulation in women resistant to clomifene
- ovarian drilling may be used in PCOS
- meftormin may be used where there is insulin insensitivity and obesity
