Infertility Flashcards by Owen Vineall

How to interpret mid luteal progesterone

Under 16- repeat and refer if chronically low
16-30- repeat
Over 30- normal indicating ovulation

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What must be done when giving in a sperm sample

Must be after of abstinence of between 2-7 days
Delivered within 1 hour to lab

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First line infertility treatment for PCOS

Lose weight especillay when overweight
Losing even just 5% can cause infertility to spontaneously resolve

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Why is gonadotrophin treatment only used later down line in PCOS

Risk of multiple pregnancy
OHSS risk higher

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What is chance of getting pregnant after 1 and 2 years

After 1 year of regular UPSI
- 85%
After 2 years of regular UPSI
- 93%

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What are the causes of infertility for couples

Men 30% of time the problem lies with them
Women
1. Ovulation problem
2. Tubal problem
3. Uterine or peritoneal problem

25% of time it is unknown

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How are ovulatory disorders classified

Class 1- hypothalamic failure
Class 2- failure of HPO axis
Class 3- ovarian failure

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What are causes of class 1 ovulation disorders

Hypothalamic dysfunction
- kallmans
- stress
- excess exercise

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What is most common class 2 ovulation disorder

PCOS
Other causes include hyperprolactinaemia, cushings

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What are causes of class 3 ovulation disorders

Ovarian failure
- dysgenesis in turners
- chemo and radiation
- premature ovarian insufficiency

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What can cause tubal, uterine and cervical causes of infertility

Previous PID
Endometriosis
Salpingectomies for ectopics
Submucosal fibroids
Any procedure or operation on reproductive organs

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Which drugs can cause subfertility in a woman

NSAIDa
Chemo (ovarian failure)
Spironolactone
Marijuana and cocaine
Post contraception
- injectables
- dermal patch
- vaginal ring

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Which contraceptives cause infertility after removal

Injectable- a year
Dermal and vaginal ring a few months

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What are terms for reduced sperm count, poor sperm motility and abnormal sperm morphology

Count- oligospermia
Motility- asthenozoospermia
Morphology- teratozoospermia

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Causes of infertility in males

Primary spermatogenesis failure
- post mumps
- torsion
- trauma
- klinefelters
- varicocele
- cryptochordism

Obstructive
- cysts
- post epidimytis
- post surgical procedure

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What are the generic causes of infertility in both women and men

Alcohol
Smoking
BMI

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Initial management of someone in primary care with infertility

Advice about smoking, alcohol, weight and drugs known to cause infertility- check necessity
If has been going on for 1 year with regular UPSI then refer
Consider early referral if meets criteria
Investigations
- for men a semen sample and screen for chlamydia
- for every woman do chlamydia screen and mid luteal progesterone
If menstruation problem do hormone screen
- gonadotrophins
- TFTs
- prolactin
- weekly progesterone until ovulation if irregular periods
Discuss psychological support- will be a focus from infertility team

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How is infertility investigated in a man in primary care

Semen analysis
Chlamydia screen

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What to do with an abnormal sperm analysis

If abnormal repeat in 3 months then refer if second one abnormal
EXCEPT REPEAT IN 2-4 weeks IF
- sperm count under 5 million or
- very anxious about results

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How is infertility investigated in a woman in primary care

Every woman
- Chlamydia screen
- mid luteal progesterone
If menstrual problems then
- gonadotrophins
- TFTs
- prolactin
- weekly progesterone until ovulation occurs

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What investigations are done in secondary care for woman with infertility

If suspected PID/endometriosis or tubal disease then offer laparascopic tubal investigation
If no suspicion of anatomical disease causing infertility then offer hysterosalpingogrpahy or hysterosalpingo- contrast USS

How does hysterosalpingography work

Catheter passed into uterus and dye injection- imaged on X-ray to detect blockage

What are management options for infertility

Medical
- clomiphene
- Gonadotrophins
- pulsatile GNRH
- dopamine agonists
Surgical
- tubal catheter
- endometrial or fibroid removal treatment
Assisted conception
- IVF
- intrauterine insemination
- intracytoplasmic sperm injection
- oocyte donor
- sperm donor

What is treatment for infertility caused by hyperprolactinaemia

Dopamine agonists

How can tubal blockage infertility be treated

1st line- if mild can attempt tubal catheterisation 2nd line- IVF

How does IVF work

Remove eggs, inseminate them, incubate for 2 days and place in uterus

When consider IVF

Tubal blockage Men with subfertility Idiopathic infertility Annovulatory treatment failure

How does intrauterine insemination work

Sperm inserted into uterus while inducing ovary with anti-oestrogens or gonadotrophins

Who is intracytoplasmic sperm injection indicated in

Erection or ejaculation issues Spinal injuries or DM Oligospermia

How does oocyte donation work

Oocytes taken from a donor after stimulation and then fertilised by partners sperm

Who is oocyte donation possible in

Woman at risk of transmitting infection or genetic disorder to child Ovarian failure from chemo/radiation Ovarian dysgenesis

Who is donor insemination indicated in

Female only couples Males with very low sperm Men at risk of transmitting genetic disease or infection

What is best option for infertility treatment in people with turners

Oocyte donation

Annovulatory infertility treatment

1st line Clomiphene 2nd line Gonadotrophins or pulsatile GNRH or dopamine agonists 3rd line IVF

Criteria for earlier infertility referral in women

36 or older and been trying for 6 months History of PID and STI Endometriosis Previous abdo or pelvic surgery Abnormal pelvic examination Known reason for infertility like chemo

Criteria for earlier infertility referral in men

History of genital pathology History of gential surgery Varicocele Abnormal genital examination Known reason for infertility like chemo

What are the problems of assisted conception

Increased risk of mutliple pregnancy OHSS risk Ectopic pregnancy Infection from invasive procedures

What is pathophysiology of OHSS

Ovaries are overstimulated and so too many follicles develop causing fluid to leak out

How is OHSS classified

Mild - abdo pain and bloating Moderate - mild with N&V and US evidence of ascites Severe - moderate with visible ascites - oligouria - HCT over 45 - hypoproteinaemia Critical - severe with anuria - VTE - tense ascites

How to monitor OHSS extravascular fluid loss

HCT

Management of mild and moderate OHSS

As an outpatient - paracetamol - oral fluids - monitor every 2-3 days - can do paracentesis if need to in outpt setting with USS

When admit with OHSS

- are unable to achieve satisfactory pain control - are unable to maintain adequate fluid intake due to nausea - show signs of worsening OHSS despite outpatient intervention - are unable to attend for regular outpatient follow-up - have critical OHSS

Who is given VTE prophylaxis with OHSS

Severe and critical Give LMWH

When do paracentesis in OHSS

Pleural effusions Severe abdo distension causing pain Oligouria unresponsive to fluids

What treatments are particulalry associated with OHSS

IVF Gonadotrophins

Normal ranges for male sperm factors

Motility- at least 50% should have normal motility Morphology- over 4% good morphology Sperm count- over 15 million is good sperm count Volume- over 1.5 ml

What is gold standard for assessing tubal patency

Laparoscopy and dye

How does clomiphene regime work

In oligomenorrheic women give a progestogen for 10 days and anticipate a withdrawal bleed. Once this happens give clomiphene on day 2 of the period and continue for 5 days It is most effective when patient on period

How long can clomiphene be given for

6 cycles as extreme ovarian cancer risk

When investigating subfertility what do to when oligomenorrhoea to investigate ovulation

Weekly progesterone

How manage infertility in PCOS in GP

If BMI over 25 recommend weight loss Ask to have regular sex for 2 years then can refer to fertility clinic for clomiphene etc