Infertility Flashcards
How to interpret mid luteal progesterone
Under 16- repeat and refer if chronically low
16-30- repeat
Over 30- normal indicating ovulation
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
First line infertility treatment for PCOS
Lose weight especillay when overweight
Losing even just 5% can cause infertility to spontaneously resolve
Why is gonadotrophin treatment only used later down line in PCOS
Risk of multiple pregnancy
OHSS risk higher
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%
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
How are ovulatory disorders classified
Class 1- hypothalamic failure
Class 2- failure of HPO axis
Class 3- ovarian failure
What are causes of class 1 ovulation disorders
Hypothalamic dysfunction
- kallmans
- stress
- excess exercise
What is most common class 2 ovulation disorder
PCOS
Other causes include hyperprolactinaemia, cushings
What are causes of class 3 ovulation disorders
Ovarian failure
- dysgenesis in turners
- chemo and radiation
- premature ovarian insufficiency
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
Which drugs can cause subfertility in a woman
NSAIDa
Chemo (ovarian failure)
Spironolactone
Marijuana and cocaine
Post contraception
- injectables
- dermal patch
- vaginal ring
Which contraceptives cause infertility after removal
Injectable- a year
Dermal and vaginal ring a few months
What are terms for reduced sperm count, poor sperm motility and abnormal sperm morphology
Count- oligospermia
Motility- asthenozoospermia
Morphology- teratozoospermia
Causes of infertility in males
Primary spermatogenesis failure
- post mumps
- torsion
- trauma
- klinefelters
- varicocele
- cryptochordism
Obstructive
- cysts
- post epidimytis
- post surgical procedure
What are the generic causes of infertility in both women and men
Alcohol
Smoking
BMI
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
How is infertility investigated in a man in primary care
Semen analysis
Chlamydia screen
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
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
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
