Infertility Flashcards
Chances of natural conception decline with increasing what?
Female age
What are the chances of conception per cycle?
20% at peak
What is there a predetermined number of in women?
Pre determined number of eggs-no new egg production following egg numbers which the female is born with
What happens as the ovarian reserve is exhausted?
Cycle irregularity begins to start by age 45 & then over the next 5-7 years menopause is reached
What is associated with the decline in egg number?
Decline in the quality of the eggs where the capacity of the egg to perform well in terms of nuclear and genetic material division also declines (important feature required to achieve a conception)
Can a decline in fertility be predicted?
NO, to date there is no fertility test that can tell whether a woman can get pregnant and have a baby
What are 4 key important factors for conception?
Ovulation=egg production cyclically
Sperm production=Good & swimming well to fertilise egg
Fertilisation=Sperm & egg to meet-happens in fallopian tube (patent & functioning well), no ejaculatory or projectile problems (sexual dysfunction) to allow adequate sperm into the female repro tract
Implantation=Uterus has to be normal
What parts are crucial for ovulation to happen?
Functioning of the hypothalamus & pituitary gland & ovaries along with the hormones has to be normal for ovulation to happen
What is the diagnostic test for ovulation?
Measure progesterone to show whether ovulation did happen in that cycle or not
What happens to the hormone levels in ovulation?
LH surge mid cycle and after ovulation progesterone goes up
What cycles are coordinated in a cyclical fashion?
Ovarian & menstrual cycles
What uterine changes occur each month?
Generate an endometrium each month which is capable of having an implantation & pregnancy
Endometrial development under the effect of ovarian hormones
Fertilisation-oestrogen plays a role and also along with progesterone plays a role in tubal transport and implantation. How does the embryo get into the uterine cavity?
Once the egg is fertilised it starts dividing into embryo
Muscular spasms drive the embryo into the uterine cavity where it implants
Endometrium is prepared under influence of hormones in order to receive the embryo & drive the process of implantation
What 6 things does natural conception rely on?
Functioning hormonal axis and gonads
Ovarian reserve
Regular ovulation
Normal sperm production
Fertilization- egg and sperm interaction patent fallopian tubes
Normal uterine cavity for implantation
What lifestyle factors can affect fertility?
Age
BMI
Smoking-can accelerate the decline in ovarian reserve
Alcohol
Recreational drug use
Stress
What is the WHO clinical definition of infertility?
Inability to conceive over a 12 month period despite exposure to regular , unprotected intercourse. Represents a prognosis based approach and provides practical guidance on when to initiate investigations.
Why are global infertility trends often unreliable?
Many different definitions (WHO (clinical), epidemiological, demographic definitions)-used inconsistently when calculating prevalence
When should people be referred for fertility issues?
No conception after one year of regular unprotected intercourse
Referral earlier if-
- Age>35 years
- Known cause for infertility
What is the difference between primary and secondary infertility?
Primary=never manage to have a pregnancy before or the man has never fathered a child
Secondary=couple have had a pregnancy before in this or in a previous relation but then have not managed to get pregnant
What are some causes of female infertility?
- Ovulatory dysfunction
- Diminishing ovarian reserve
- Endometriosis
- Uterine factor
- Tubal factor
What may cause male infertility?
- Problems in producing hormones for sperm production
- Blockage of sperm transport
- Erection & ejaculation problems
- Sperm production problems
How is it checked that there are eggs available?
Age
Ovarian reserve test- blood test and scan
Blood test- FSH, D1-D5 of cycle (<10 iu/L)
AMH (5.0-25.0pmol/L)
USS- Antral follicular count
AMH=Anti-mullerian hormone – can be measured at any time in the cycle to give an indication of whether the ovarian reserve is satisfactory
What investigations are used to check that ovulation is happening?
Used by couples-
natural methods(BBT, cervical mucus)
LH ovulation kits (measures peak that happens mid cycle)
ovulation calendar
Used to investigate-
D21 serum progesterone
D21-test done on day 21 of the cycle when it is expected that the hormone level will have reached a peak-any levels over 20 are suggestive of ovulatory cycles
What are the natural methods used for ovulation detection?
Progesterone rise that happens post ovulation-slightly higher temps can be recorded
Cervical mucus discharge-maximum around the time of ovulation (looks quite thin & watery)
How is ovulation diagnosed?
Progesterone levels taken at appropriate time - day 21 only if 28/30 day cycle
Levels > 20nmol/l show satisfactory ovulation
What can be used to see if there is sperm available?
Semen analysis
If these parameters are below that it does not mean total infertility but it means reduced infertility
What needs to be the case in order for the egg and sperm to meet
Intercourse - with no sexual difficulties (e.g. pain or discomfort that prevents regular intercourse or that the man doesn’t have any erection or ejaculation problems)
Patent fallopian tubes
How is the patency of fallopian tubes checked?
If no pelvic infection or gynaecological problem in past- Hysterosalpingogram(HSG)
If any of above- Laparoscopic dye test
How is a HSG taken?
Catheter, dye and a radiograph
How is laparoscopy carried out?
Laparoscope to inspect pelvic organs then put in methylene blue dye & see the flow of that out of the tubes
Any additional minor procedures can be carried out at the same time as necessary
What other tests could be carried out?
Serum prolactin
Thyroid function test
Chlamydia screening
Pelvic Ultrasound for uterine problems
Also check- Rubella immunity
Cervical smear up to date
What are the potential broad category causes of infertility?
Female, male, combined or unexplained
How are ovulation disorders managed?
Optimise body weight, Healthy life
style, Exercise
Medication (ovulation induction)
- Clomiphene citrate-6 cycles oral tablets
- Gonadotrophins
Laparoscopic ovarian drilling
What are the options if there is a very low count or no sperm (azoospermia)?
Medical treatments- gonadotrophins
Surgical sperm retrieval- epididymis/testis
Donor sperm- intrauterine insemination
ICSI (intracytoplasmic sperm injection)
What can be done in the cases of tubal problems?
Role of surgery is limited to mild tubal disease
IVF (blocked tubes removed to make IVF suitable for them)
What are other treatments for 1) Endometriosis & 2) Uterine surgery?
Endometriosis-Ablation or resection of spots, adhesiolysis, cystectomy for endometrioma
Uterine surgery- removal polyp/fibroid, adhesiolysis for synechiae
What is an option for unresolved infertility?
IVF (In vitro fertilisation)- egg (oocyte) + sperm=embryo
What is the role of Human Fertilisation & Embryology Authority (HFEA)?
Regulatory authority
Licensing
Inspections
Forms - registration, treatment, outcome
Register
What eggs can be used for IVF?
Own eggs-gonadotrophin induced superovulation
Donor eggs - age (poor ovarian reserve)
poor quality
ovarian failure
genetic cause
How is sperm got for IVF?
Partner-
Fresh sample on day of egg collection
Frozen sample (thawed)from surgical retrieval or fertility preservation
Donor sperm- Single women
Same sex relationship
Azoospermia(no sperm)
Genetic cause
Infection (HIV, HepB,HepC)
What are the key steps for the IVF process?
Controlled ovarian stimulation
Follicular monitoring
Timing ovulation
Egg collection
Lab fertilization-Insemination/ICSI
Incubation/ embryo development
Embryo transfer-done under US guidance
Progesterone support
Final injection of hCG hormone to trigger ovulation & then 36 hrs=egg retrieval (via transvaginal US)
Support is given in the form of vaginal pessaries to maintain the endometrium for pregnancy
How are embryos frozen and stored for IVF?
Technique of freezing=vitrification (straws frozen in liquid nitrogen)- can be kept in the freezing for ~10 yrs – can use it when ready for subsequent cycles
Each embryo stored in labelled/colour coded ‘straw’
In IVF what is done post embryo transfer?
Progesterone pessaries
Normal activity
Pregnancy test after 2 weeks
If positive- scan at 7 weeks
What are the risks of IVF?
Ovarian hyperstimulation syndrome (OHSS)
Multiple pregnancy
Medication side effects
Procedure related
- Over response of the ovaries-can get production of multiple follicles which can give rise to symptoms
- Egg recovery-risk of bleeding or infection
Are there any negative long term affects of IVF?
Children born- no difference as per short term data.
Risk of ovarian cancer not confirmed
Absolute risk to women and children low
