Infertility Flashcards
Definition Infertility
Inability to conceive after 1-2 years of regular unprotected sexual intercouse in absence of known reporductive pathology
Incidence of infertility in couples
15% couples, 70% suffer primary infertility and 30% suffer secondary infertility
Causes of Female infertility
- Most common Anovulatory infertility a) Ovarian dysfunction ie PCOS with normal gonadotrophins
b) Hypergonadotrophic hypogonadism: Failure of ovary to respond with abnormal karyotype IE Swyers or Turners, Normal karyotype with gonadyl development issue or premature ovarian failure. Other: Chemoradiation, AI dysfunction, Infections.
c) Hypogonadotrophic hypogonadism: Failure of pituitary to produce FSH: Reversible ie Weight loss, excess excercise, anorexia, CAH, Cushings, Prolactinoma, Chronic illness irreversible: Sheehans, Kallmans, Malignant pituitary tumours etc - Tubal damage:
a) Infection usually secondary to PID
b) Endometriosis inflammatory response to endometriosis causes adhesions and tubal damage - Uterine
a) Uterine adhesions secondary to infection or trauma
b)Cavity distortion ie submucous fibroids
c) Congenital anomalies
Causes Male factor infertility
- Primary testicular dysfunction
a) Failure of spermatogenesis secondary to trauma or infection/ Chemo
b) Microdeletions of Y chromosome
- azoospermia
- oligospermia
Needs karyotyping to dx ie Klinefelters - Obstructive: Azoospermia
- Endocrine: Impotence
- Autoimmune
- Drugs: Tobacco, ETOH, Marijuana affect sperm production and function
Anabolic steroids affect spermatogenesis reversibly
ED secondary to beta blockers
Chemo destroys germ cell lines: Irreversible azoospermia - Environmental: heat, radiation, chemicals
- Varicocoele
Assessment of Infertility
Couple problem; Should therefore be assessed together. BUT need individual assessment to exclude DV and sicuss possible STI
Pertinent History Female infertility
- Age: reduction of ovarian reserve with increasing age
- Menstrual history
- Weight gain or loss
- Obs history: -Prev preg time to conceive, outcome, problems in pregnancy, delivery and postpartum. ? Same partner
- Contraception history
- Medical problems and Medications
Pertinent female examination
- BMI
- Signs of endo disease ie acne, hirsutism, balding, acanthosis nigrans, virilisation, visual field defects, signs of thyroid disease
- Bimanual exam: Enlarged uterus, Mobility uterus ? Endo nodules
Pertinent female infertility investigations
- General: Rubella, Opportunistic CST, HIV, Hep B and C
- Ovarian reserve: Day 2-5 LH, FSH (<10)and Oestradiol (>70) normal
- Ovulation: Midcycle prog (>30)
Other as indicated:
If suspect PCOS
Add: 17 OH Prog to exclude CAH
FAI - Prolactin
- Tubal patency tests:
a)HSG in first 10/7 cycle
b) Lap and Dye - TVUS: Identify fibroids, polyps and adhesions, Ovarian morphology, hydrosalpinges, adhesions and signs of endo
Pertinent Male History
Medical history including medications and drugs
History of Smoking, illicit substance use and alcohol
Children from prior relationships
Pertinent Male examination
BMI
Testicular exam
Pertinent male investigations
- Semen analysis: Large variation in sperm quality
- Asthenozoospermia: Reduced sperm motility
- Oligozoospermia: Concentration <20 x 10 power 6/ml
- Teratozoospermia: Abnormal morphology
- Hypospermia: reduced volume of ejaculate
Normal volume = 2ml
Total sperm: > 40
Morph forms > 15%
Motility >50%
>25% forward progression
- FSH and Testo
- Consider Karyotype
- Testicular Biopsy to determine if sperm available for ICSI
Discuss general measures to improve fertility
Normalise BMI
Stop smoking
Cut ETOH intake
Regular unprotected intercoure ( 60% will conceive within 3 years of unexplained infertility)
Treatment of anovulatory
- Aim to induce ovulation
1. Hypergonad hypo: OI not possible, consider ovum donation
2. Hypo Hypo: OI possible - treat cause if possible ie decrease prolactin
- Daily injection gonadotrophin or pulsatile infusion
3. PCOS: Weight reduction in obese women will lead to ovulation in 40-60%
4. Clomiphene: Risk of Multi preg
start day 2 of cycle: 50mf daily for five days
For 3 cycles, If nil
increase to 100mg daily
Alternative: Letrozole: 2,5mg daily day 2-6 of cycle, for 3 cycles
If nil increase to 5mg daily up to 7,5mg daily
Alternative: Daily gonadotrophins
+ timed intercourse
+/- IUI
Treatment of tubal factory infertility
- If ameanable: Surgical correction
- Has increased risk of ectopic
Alternative: IVF
Treatment of endo related infertility
Medical mx not indicted
surgery: Mild to mod endo improves natural conception rates post op
Surgery for severe endo may improve success with IVF
Treatment of uterine factors
Impact debatable
consider myomectomy etc
Treatment of unexplained infertility
- Expectant: 60% will conceive within 3 years
- Ovarian stimulation with timed intercourse or IUI: 10 - 15% success with each cycle
- IVF if nil success after 3 cycles of IUI
Methods of Ovulation Induction
- Clomiphene Citrate
- Gonadotrophin injection
- Gonadotrophin pump
- Aromatase Inhibitors ie Letrozole
Explain IVF cycle
- Gonadotrophins are given to stimulate follicular development in the ovary
- Gonadotrophin agonist or antagonists given to prevent endogenous LH secretion to avoid premature ovulation
- HCG given to triger re entry into meiosis and expulsion of first polar body
- Follicles aspirated 36-38 hours later (90% follicles yield oocytes)via TVUS guided needle
- Oocytes and sperm incubated overnight and if fertilised embryos incubated further
- Embryo transfered 2/7 post fertilisation into uterine cavity under ultrasound guidance
- Luteal support with either HCG injections or vaginal progesterone
Frozen embryos can be used later wit natural or unstimulated cycles
Complications of IVF
- Multiple pregnancy
- Ovarian hyperstimulation: Systemic disease with release of vasoactive products from overstimulated ovaries
Characterised by increased capillary permeability with leakage of fluid to third space leading to intravascular dehydration. If severe life threatening
Risks: age <30
Lean physique
PCOS
HCG trigger
Superovulation >20 oocytes
Rapidly rising Oestradiol
Multiple preg
Prev OHSS
How to prevent OHSS
- ID high risk patients
- wihtold trigger if excessive follicular development
- WIthhold embryo transfer
- Luteal phase support with prog rather than HCG
Clinical features of OHSS
Mild: Abdo distension, mild pain, ovaries <8cm
Moderate: Mild OHSS with ultrasound evidence of ascites, nausea, vomiting, diarrhoea and ovarian size 8-12cm
Severe: Any of following
- Clinical ascites
- Hydrothorax
- Haemoconcentration
- Electrolyte disturbance
- Oliguria with increased creatinine
- Ovarian size >12cm
Critical
- Tense ascites or large hydrothorax
- HCT >55%
- WCC >25
- Oliguria/anuria
- Thromboembolism
- ARDS
Management of OHSS
Mild: Outpatient`; Motivated and monitor urine output and obs. Daily liason with IVF centre
Mod-severe or critical:
Strict adherence to local protocol
- 4 hourly pulse, BP nd temp
- daily weight and abdo circum
- Urinary output
- Strict fluid balance
- FBE, U and E
- US: Monitor Ascites and ovarian size
- CSR: If suspect pleural effusion
- Thromboprophylaxis with clexane
Consider drainage for tense ascites, pleural or pericardial effusions
- Colloid infusion if large volume
MDT: ICU, Anaesthetics, Haematology, renal physician
