Infertility Flashcards
When should a couple be investigated for infertility?
- after trying to conceive without success for 12 months
OR
- failure to conceive after 6 months in women > 35
time is precious > 35 as ovarian stores are likely to be already reduced
What are the 5 possible causes of infertility?
- sperm problems
- ovulation problems
- tubal problems
- uterine problems
- unexplained
the causes are a mixture of male + female in 40% cases
What general advice is given to couples trying to conceive?
- take 400mcg folic acid every day
- aim for intercourse every 2-3 days
- aim for a healthy BMI
- reduce stress (affects libido + relationship)
- avoid timing intercourse
- reduce/avoid smoking / alcohol
timing intercourse to conincide with ovulation is not necessary + can lead to increased stress in the relationship
What initial investigations are performed in primary care?
- chlamydia screening
- BMI calculation
- semen analysis
- female hormone testing
- Rubella immunity in the mother
low BMI could indicate anovulation and high could indicate PCOS
What are the 3 tests performed in female hormone testing?
- serum LH and FSH on day 2-5 of the cycle
- serum progesterone on day 21 (or 7 days from the end of the cycle if not 28 days)
- anti-Mullerian hormone
What other female hormone tests may be done if indicated?
- thyroid function tests (if suggestive symptoms)
- prolactin if symptoms of galactorrhoea or amenorrhoea
hyperprolactinaemia can cause anovulation
What may a high serum FSH indicate?
poor ovarian reserve
- the number of follicles the woman has left in her ovaries is low
- the pituitary gland is producing extra FSH to stimulate follicular development
What may a high serum LH indicate?
PCOS
What may a high serum progesterone indicate?
- a high progesterone on day 21 indicates that ovulation has occurred
- the corpus luteum has formed and is secreting progesterone
What does a high anti-Mullerian hormone indicate?
good ovarian reserve
- this is secreted by the granulosa cells in the follicles
- it falls as the eggs are depleted
- it is the most accurate marker of ovarian reserve and can be measured at any time in the cycle
What further investigations may be performed in secondary care?
pelvic US:
- looks for polycystic ovaries or other structural abnormalities
hysterosalpingogram:
- looks for patency of fallopian tubes
laparoscopy + dye test:
- looks for patency of fallopian tubes, adhesions + endometriosis
What is assessed on a hysterosalpingogram?
- assesses the shape of the uterus
AND
- the patency of the fallopian tubes
- it has a therapeutic benefit with the rate of conception increasing after the scan
What procedure can be performed at the same time as hysterosalpingotomy?
tubal cannulation
- this involves opening up a blocked fallopian tube under XR guidance
How is a hysterosalpingogram performed?
- a catheter is inserted into the cervix
- a contrast medium is injected through the catheter to fill the uterine cavity + fallopian tubes
- XR images are taken
- if one of the tubes does not fill with dye, this indicates that it is blocked
What should be performed prior to a hysterosalpingogram?
screening for chlamydia + gonorrhoea
What medication may be given prior to a hysterosalpingogram?
prophylactic antibiotics
- there is a risk of infection with the procedure
- abx given to patients with dilated tubes or history of pelvic infection
What is involved in a laparoscopy + dye test?
- during the procedure, dye is injected into the uterus
- it should be seen entering the fallopian tubes and spilling out the ends
- absence of this pattern suggests tubal obstruction
- endometriosis + pelvic adhesions can also be assessed / treated
What are the 6 management options for anovulation causing infertility?
- weight loss (for PCOS)
- clomifene (stimulates ovulation)
- letrozole (alternative to clomifene)
- gonadotropins (used in women resistant to clomifene)
- ovarian drilling (used in PCOS)
- metformin if there is obesity / insulin insensitivity
When is clomifene given?
days 2 - 6 of the menstrual cycle
How does clomifene work?
- it is an anti-oestrogen
- it stops the negative feeback of oestrogen on the hypothalamus
- this results in a greater release of GnRH
- and a subsequent greater release of FSH + LH
What is involved in ovarian drilling?
- laparoscopy is used to puncture multiple holes in the ovaries
- this involves diathermy or laser therapy
- this can improve the hormonal profile + result in regular ovulation
What are the options for women with tubal factors affecting fertility?
- tubal cannulation during hysterosalpingogram
- laparoscopy to remove adhesions / endometriosis
- IVF
What is involved in the management of uterine factors affecting fertility?
surgery to correct polyps, adhesions or structural abnormalities
What are the options for management of sperm problems?
- surgical sperm retrieval
- surgical correction of an obstruction in the vas deferens
- intra-uterine insemination
- intracytoplasmic sperm injection (ICSI)
- donor insemination with sperm from a donor
What is surgical sperm retrieval and when is it performed?
- used when a blockage in the vas deferens is preventing sperm from reaching ejaculated semen
- a needle + syringe is used to collect sperm from the epididymis through the scrotum
What is intra-uterine insemination?
- collection and separation of high quality sperm
- the high quality sperm are injected directly into the uterus
it is not known whether this is any better than normal intercourse
What is intracytoplasmic sperm injection?
- sperm are injected directly into the cytoplasm of an egg
- these fertilised eggs become embryos that are injected into the uterus
When is ISCI a good option?
- sperm motility issues
- very low sperm count
