Infertility Flashcards

1
Q

When should a couple be investigated for infertility?

A
  • 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

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2
Q

What are the 5 possible causes of infertility?

A
  1. sperm problems
  2. ovulation problems
  3. tubal problems
  4. uterine problems
  5. unexplained

the causes are a mixture of male + female in 40% cases

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3
Q

What general advice is given to couples trying to conceive?

A
  • 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

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4
Q

What initial investigations are performed in primary care?

A
  • chlamydia screening
  • BMI calculation
  • semen analysis
  • female hormone testing
  • Rubella immunity in the mother

low BMI could indicate anovulation and high could indicate PCOS

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5
Q

What are the 3 tests performed in female hormone testing?

A
  • 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
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6
Q

What other female hormone tests may be done if indicated?

A
  • thyroid function tests (if suggestive symptoms)
  • prolactin if symptoms of galactorrhoea or amenorrhoea

hyperprolactinaemia can cause anovulation

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7
Q

What may a high serum FSH indicate?

A

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
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8
Q

What may a high serum LH indicate?

A

PCOS

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9
Q

What may a high serum progesterone indicate?

A
  • a high progesterone on day 21 indicates that ovulation has occurred
  • the corpus luteum has formed and is secreting progesterone
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10
Q

What does a high anti-Mullerian hormone indicate?

A

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
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11
Q

What further investigations may be performed in secondary care?

A

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
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12
Q

What is assessed on a hysterosalpingogram?

A
  • 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
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13
Q

What procedure can be performed at the same time as hysterosalpingotomy?

A

tubal cannulation

  • this involves opening up a blocked fallopian tube under XR guidance
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14
Q

How is a hysterosalpingogram performed?

A
  • 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
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15
Q

What should be performed prior to a hysterosalpingogram?

A

screening for chlamydia + gonorrhoea

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16
Q

What medication may be given prior to a hysterosalpingogram?

A

prophylactic antibiotics

  • there is a risk of infection with the procedure
  • abx given to patients with dilated tubes or history of pelvic infection
17
Q

What is involved in a laparoscopy + dye test?

A
  • 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
18
Q

What are the 6 management options for anovulation causing infertility?

A
  • 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
19
Q

When is clomifene given?

A

days 2 - 6 of the menstrual cycle

20
Q

How does clomifene work?

A
  • 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
21
Q

What is involved in ovarian drilling?

A
  • 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
22
Q

What are the options for women with tubal factors affecting fertility?

A
  • tubal cannulation during hysterosalpingogram
  • laparoscopy to remove adhesions / endometriosis
  • IVF
23
Q

What is involved in the management of uterine factors affecting fertility?

A

surgery to correct polyps, adhesions or structural abnormalities

24
Q

What are the options for management of sperm problems?

A
  • 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
25
Q

What is surgical sperm retrieval and when is it performed?

A
  • 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
26
Q

What is intra-uterine insemination?

A
  • 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

27
Q

What is intracytoplasmic sperm injection?

A
  • sperm are injected directly into the cytoplasm of an egg
  • these fertilised eggs become embryos that are injected into the uterus
28
Q

When is ISCI a good option?

A
  • sperm motility issues
  • very low sperm count