Infertility Flashcards
What proportion of couples fail to conceive naturally?
1/7
After trying to conceive for how long should investigations and referrals for infertility be started? (2 options)
- 12 months
- 6 months if: woman 35+ yrs
What are the causes of infertility? (5 things)
- Sperm (30%)
- Ovulation (20%)
- Tubal (15%)
- Uterine (10%)
- Unexplained (20%)
What is some general advice for infertility? (5 things)
- Woman takes 400mcg folic acid daily
- Have healthy BMI
- X Smoking / Alcohol
- Reduce stress (fx libido + relationship)
- Intercourse every 2-3 days
What initial investigations should you do in primary care for infertility? (5 things)
- BMI
- Chlamydia screening
- Semen analysis
- Female hormone testing
- Rubella immunity in mother
What does a LOW BMI suggest the cause of infertility is?
Anovulation
What does a HIGH BMI suggest the cause of infertility is?
PCOS
What does Female hormone testing involve? (5 things)
- Serum LH + FSH
- Serum progesterone
- Anti-Mullerian hormone
- TFTs (if symptoms suggest dis)
- Prolactin (when symptoms of galactorrhoea / amenorrhoea)
Why should you check Prolactin in infertility?
Hyperprolactinaemia causes anovulation
Which day range is Serum LH + FSH checked?
Day 2-5
Which day is Serum progesterone checked?
Day 21
(or 7 days b4 end of cycle if not 28 day cycle)
What does High FSH suggest?
Poor ovarian reserve (aka number of follicles left in ovaries)
What explains the High FSH in poor ovarian reserve?
Pit gland prod extra FSH in attempt to stimulate follicular dev
What does Low LH suggest?
PCOS
What does a rise in Progesterone @ day 21 indicate? (2 things)
- Ovulation has occurred
- Corpus luteum formed + started secreting progesterone
When in the cycle can Anti-Mullerian hormone be tested for?
Anytime
What is Anti-Mullerian hormone a marker for?
Most accurate marker of ovarian reserve
What is Anti-Mullerian hormone released by?
Granulosa cells in follicles
What does Low Anti-Mullerian hormone suggest?
Eggs are depleted
What further investigations should you for infertility in Secondary care? (3 things)
- US Pelvis
- Hysterosalpingogram
- Laparoscopy + Dye test
What are you looking for in a US Pelvis of infertility? (2 things)
- PCOS
- Structural abn in uterus
What are you looking for in a Hysterosalpingogram of infertility?
Fallopian tube patency
What are you looking for in a Laparoscopy + Dye test of infertility? (3 things)
- Fallopian tube patency
- Adhesions
- Endometriosis
What is a benefit of a Hysterosalpingogram?
Can do Tubal cannulation during it –> opens up tube –> restores fertility
What is a risk of having a Hysterosalpingogram?
Infection
What precautions are taken with Hysterosalpingogram to reduce risk of infection? (2 things)
- Prophylactic abx
- Chlamydia + Gonorrhoea screening b4 hand
What is a benefit of a Laparoscopy?
Can treat adhesions / endometriosis on the job
What are the management options for infertility caused by ANOVULATION? (6 things)
- Weight loss (if overweight +/- PCOS)
- Clomifene
- Letrozole (instead of clomifene)
- Gonadotropins (if resistant to clomifene)
- Ovarian drilling (if PCOS)
- Metformin (for insulin sensitivity / obesity related to PCOS)
What drug class in Clomifene?
Anti-oestrogen (selective oestrogen receptor modulator)
What day range is Clomifene given?
Days 2-6 of menstrual cycle
What are the physiological steps of Clomifene in restoring fertility? (4 steps)
- Stops negative feedback of oestrogen on hypothalamus
- Increased GnRH release
- Increased FSH + LH
- Ovulation
What are the physiological steps of Ovarian drilling in restoring fertility? (3 steps)
- Multiple holes drilled in ovaries using diathermy / laser (@ laparoscopy)
- Womans hormone profile improved
- Regular ovulation
What are the management options for infertility caused by TUBAL DEFECTS? (3 things)
- Tubal cannulation @ hysterosalpingogram
- Laparoscopy to remove adhesions / endometriosis
- IVF
What is the management option for infertility caused by Uterine DEFECTS?
Surgery to correct polyps / adhesions / structural abn
What are the management options for infertility caused by Sperm defects? (5 things)
- Surgical sperm retrieval
- Surgical correction of vas deferens obst
- Intra-uterine insemination
- Intracytoplasmic sperm infection (ICSI)
- Donor insemination
What does Intra-uterine insemination involve? (2 steps)
- Collecting + separating high quality sperm
- Injecting them directly into uterus
What does Intracytoplasmic sperm injection (ICSI) involve? (2 steps)
- Injecting sperm directly into cytoplasm of egg (which then becomes embyro)
- Embryo injected into uterus
When is Intracytoplasmic sperm injection (ICSI) useful? (2 things)
- Sperm motility issues
- Low sperm count
