infertility Flashcards
define infertility
inability of heterosexual couples to acheieve a clinical pregnancy within 12 months od beginning regular unprotected sexual intercourse
define primary and secondary infertiliy
primary - no previous pregnancies
secondary- at least one previous pregnancy
incidence of infertility in the popoulation
1 in 7 couples at some point
in a normal fertile couple what are the percentage changes of getting pregnant after:
1 month
6 months
1 year
2years
1 month- 30%
6 months- 60%
1 year- 84%
2 years- 92%
factors affecting fertility 5
age
-mostly female issue
-some evidence of male age influence
previous pregnancy
duration of sub-fertility
- if over 3 years chance of conception only 1-3% per cycle
timing of intercourse
weight
how does timing of intercourse affect fertility
sperms needs to be deposited BEFORE ovulation
-as progesterone affects cervical mucus
2-3 times a week
how does weight affect fertility
less likely if BMI <18.5 or > 30
other weight related pregnancy problems important also
- increased risk of miscarriage
-GDM
-PIH (pregnancy induced hypertension)
-DVT
state the holy triad of reproductive physiology
sperm
egg
meet and implant
how can causes of infertility be classified
-percentage chance for each
male - 30%
ovulatory - 25%
unexplaiend 25%
tubal 15%
endometrosis 5%
*-often combined
management prinicples of infetility 4
both partenrs should be involved throughout
inital health promotion
history, exam, investigations
treatment
health promotion domains for inferility 6
smoking
alcohol
recreational drugs
obesity
-takes longer to conceive
-males >30MBI also reduced fertility
low BMIs (<19) with oligo-amenorrhoea
folic acid helps avoid NTDs (neural tube defects)
how does smoking affect fertility 2
reduces female ferility (even passive)
reduces male sperm quality
*-refer for smoking cessation
alcohol consumption for males and females trying to conceive
female -1-2 units once or twice a week
male - 3-4 units a day is OK (but intoxication affects sperm quality)
which recreational drugs in partiuclar affect infertility
esp body building supplkemtns for male s
-decreases sperm activity and takes months to recover
regarding semen analysis
-when is the sample collected
after 2-5 days of abstienece
what laboratory factors are used in semen analysis 3
concentration
total motility
normal forms
regarding semen analysis
-what is the minimum concentration
> 15mill/ml
regarding semen analysis
-what is the minimum total motility
> 40%
regarding semen analysis
-what is the minimum normal forms
*-what is included in assessing normal forms
≥4%
-count, motiltiy, morphology
other factors assessed in semen analysis 3
volume – ≥1.5ml
progressive motility - >32%
vitality – 58%
what can cause an abnormal semen analysis result 3
low (or absent) sperm numbers
low motility
poor quality
terminology for semen abnormalities
azoospermia
absent sperm
terminology for semen abnormalities
oligospermia
very few sperm
terminology for semen abnormalities
asthenospermia
very immotile sperm
terminology for semen abnormalities
teratospermia
abnormal morphology
how can causes of male subfertility be classified 3
defects in:
-sperm transportation
-sperm production
-hypogonadotrophism (rare)
what is assessed in a subfertile male 5
seminal analysis
history
testicular examination
FSH
karyotype if severe oligo or azoospermia
-? CF carrier; Y deletions
regarding semen analysis
-when is the sample collected
after 2-5 days of abstinence
-analysed in dedicated lab with strict regulations
how can causes of azoospermia be split
obstructive
non obstructive
basic pathophys of obstructive azoospermia
normal spermatogenesis
inability to leave in ejaculate
causes of obstructive azoospermia 2
blockage in epididymis or vas deferens
congenital absence of vas deferens (TEST CF)
basic pathophys of non obstrutive azoospermia
testicular failure (high FSH)
-small testicular volumes
testing for non obstrutive azoospermia
biopsy - ?any spermatogenesis
karyotype for ?XXY (klinefelters)
Y microdeltions
other than obstrutive and non obsturtive azoospermia what is a third type
-how can it be caused
RARE
=failure to stimjalte speramtogensis
=hypogonadotorphic hypogonadism
-low FSH
male subfertility management options 2
IVF with intracytoplasmic sperm injection (ICSI)
-resuls are better than IVF
-better for obstrutive than non obstructive azoospermia
donor insemination
-if ICSI not feasible eg. if no quality sperm extracted
how can female infertility be split
ovulatory
tubal
when does ovulation occur in the cycle
-what is released
day 21
-progesterone
regarding women infertility
-define group 1
women with primary or secondary amenorrheoea
-low levels of endogenous gonadotorpins
-negilibile endogenous oestrogen activity
regarding women infertility
-define group 2
anovulatoin associated with a variety of menstural disorders (including amenorrhea)
-exhibit distinct endogenous oestorgen activity whose urinary and serum gonadotropins are in the normal range
regarding women infertility
-define group 3
primary or seocndary ammenorhea due to primary ovarian failure with low endogenous oestrogen acitivyt and pathologically high gonandotooin levels
summaries the groups of infertile women 3
1- primary or secondary amenorrhoea
-low gonadotropins, no (v low) oestrogen
2- anovulation due to menstrual disorders
-normalgonadotorpins, normal oestrogen
3-primary or secondary amenorrhea due to primary ovarian failure
- high gonadotropins, low oestrogen
regarding hypothalamic pituitraty fialure resulting in infertility in women (group 1)
-what can affect the hypothalamic part 3
weight stress exercise
craniopharyngioma
kallmans syndrome
regarding hypothalamic pituitraty fialure resulting in infertility in women (group 1)
-what can affect the pituitary part 1
adenoma
what are the lab findings in gorup 1 infertility in women 4
-what investigation could be useful in this group
decreased FSH
decreased LH
decreased E2
normal or increasted PRL (prolactin)
-MRI check for spcare occupying lesion
management of group 1 infertile women 2
-medical managemnt 2
increase BMI and exercise in moderation
-treat the cause
medical management
-GnRH agonist
-given in pump - pulsatile release- mimic normality
-limited aviablaibly
-advantages include mono-ovulation and increased live birth success
;gonadotropins (FSH/LH)
-problems with ovairna hyperstimulation
-multiple ovulation
-multiple pregnancy
cuases of group 2 (hypothalamic-pituitary dysfunction) infertility in women 5
85% anovulatory suibferitlity
-mainly PCOS/PCO
others:
-hyperprolactinaemia
-hypothyroid
-hyperthyroid
-adrenal insufficiency
how is hyeprporlactinaemia treated as a cuase of infertility
dopamine agnoist
-cabergoline or bromocriptine
hormoen levels in PCOS (group 2 inferiltity) 4
Normally this ratio is about 1:1 – meaning the FSH and LH levels in the blood are similar. FSH and LH are often both in the range of about 4-8 in young fertile women. In women with polycystic ovaries the LH to FSH ratio is often higher – for example 2:1, or even 3:1
E2 normal
prolactin normal
free andogen index (FAI) increased
what is the most common form of anovulatory infertiltiy
polycycstic ovarian syndrome (PCOS)
prevalence of PCOS
20% of woemn
what criteria is used for PCOS diagnosis
-how many elements of this criteria are need for diagnosis
rotterdam criteria
- 2 of 3
state the cirteria for PCOS diagnosis (rotterdam criteria) 3
clinical or biochemical evidence
oligomenorrhoea/amenorrhoea
ultrasound feature of PCO
state the cirteria for PCOS diagnosis (rotterdam criteria) 3
clinical or biochemical evidence
oligomenorrhoea/amenorrhoea
ultrasound feature of PCOS
what is the ultrasound finding in PCOS
string of pearls
how does PCOS affect feritltiy
ovulatory function
oocyte quality
endometrial receptivity
*? secondary to obestiy, metabolic and inflammatory distrubance s
mainstay of PCOS managemtn
weight loss
-even if normal BMI - 10% weight loss- increased ovulation to approx 80%
define ovarian drilling as a treatment for PCOS infertility
Ovarian drilling involves laparoscopic surgery. The surgeon punctures multiple holes in the ovaries using diathermy or laser therapy. This can improve the woman’s hormonal profile and result in regular ovulation and fertility.
-as effective as GnRH for PCOS
-80% ovulation
-14% miscarraige
-use after failed medical management
first line medical PCOS fertiltiy managemnt
letrozole
MOA of letrozole for PCOS infertilityh
armoatase inhibitor
-block ostreogen biosynthesis -> blocks negative feedback -> increased FHS-> ovulation stimulation
previous first line PCOS feritlity medical mangemtn
clomiphene
MOA of clomiphene for PCOS feritlity
SERM
-selective oestrogen receptor modulator
-blocjs E2 receptor at pituitary
blocks negfative geedback-> increased fSH-> ovulation stimulation
why is letrozole preferred over clomiphene for fertiltiyu management 4
increased ovulation and pregnancy rates
has a decreased risk of multiple preganncy
decreased risk of ovarian cancer
decreased risk of ovarian hyperstimulation
when is IVF used in PCOS feritliy managemnt
stimulation after GnRH analoauge down reulafion of pituitary with FSH injections to stimulate ovulation
define ovarina hyperstimulatoin
ovaries over respond to gonadotrophin injfections
-ssytemic diseas resulting from release of vasoactive products from hyperstimulated ovaries
1% risk but 5% risk in PCOS
severe manifestiaatiosn of ovarian hyeprsitmulation 4
thrombosis
renal dysfunction
liver dysfunction
adult respiratory distress syndrome
lab findings in group 3 (ovarian fialure/ insuffiences) infertility in women 2
increased FHS
decreased E2
lab findings in group 3 (ovarian fialure/ insuffiences) infertility in women 2
cuaincreased FHS
decreased E2
causes of group 3 (ovarian fialure/insuffifences) inferitlity in women 9
Idiopatihic
Chemo/XRT
Surgical removal of ovaries
Autoimmune
Chromosomal
Turners (45XO)/ Turners mosaic
Pure gonadal dysgenesis
Androgen insensitivity (46XY)
Fragile X
most common group 3 (ovarian fialure/insuffieincey) cuase
premature ovarian insuffiiency (POI)
can concieve with no treatment but pregnancy rates v low
other options for managemnt of group 3 (ovarian fialure/insuffieincey) than conseravitely 5
IVF
emrbyo donation
adoption
fostering
accepting childlessness
how are a womens fallopian tubes assessed for dysfunction in infertility 3
hysterosalpingogram (HSG)
-X-ray with radio-opaque dye into the uterus
laparosocpy and dye test
-consider risks assoc w laparscopy
-allows assessment of pelvis
hysterosalpingo-contras ultrasonography (Hy-Co-Sy)
-assess tubal and uterine pathology
elegibiltiy in scotland for assissted conception services 5
-female must be less than 43 yo by time treatment is completed AND less than 42 years by time screening is completed
female BMI 18.5-30
both partners non smoking for at least 3 months before being placed on waiting lists
at least one partner have no biliogcla child
neither you or partner have been sterilied
cohabitng stable relationship for greater than 2 years
what infections are tested for at cervical screening for assisted conception services 5
rubella
HIV
\
hep c
hep B
chlamydia
techniques for assisted conception services
intrauterine insemination ± ovulation inducion
IVF- sperm feritlzies egg on its own
intracystosplasmic sperm injection
-singe sperm injected into mature egg
rates of live birth rate for assisted conception serivecs
~25% for each cycle
