Infertility Flashcards
What percentage of couples suffering from infertility will conceive spontaneously or with relatively simple advice?
50%
What are some reasons for the increase in incidence of infertility?
- Older women
- Rise in chlamydia infections
- Increase in obesity
- Increase in male factor infertility
- Increasing awareness of treatments
- Change in expectations
What percentage of couples conceive within 6 months of trying?
75%
What percentage of couples conceive within 12 months of trying?
90%
What percentage of couples conceive within 24 months of trying?
2 years
How long after attempted conception is IVF offered by NHS Scotland?
2 years
What is infertility?
Failure to achieve a clinical pregnancy after 12 months or more of regular, unprotected sexual intercourse (In absence of a known reason) in a couple who have never had a child
What is meant by primary infertility?
The couple has never concieved before
What is meant by secondary infertility?
The couple has previously conceived, although this may not have been successful (e.g. miscarriage, ectopic pregnancy)
What are some factors that increase fertility?
- Women aged under 30
- Previous pregnancy
- <3 years trying to conceive
- Intercourse around ovulation
- BMI 18.5 - 30 m/kg2
- Both partners non smokers
- Caffeine intake less than 2 cups daily
- No use of recreational drugs
What are some causes of infertility in females?
- Tubal disease
- Fibroids
- Endometriosis/adenomyosis
- Weight
- Age
- Ovulatory disorders (Causing anovulatory infertility)
What are some conditions that can cause anovulatory infertility?
Ovulatory disorders
Chronic renal failure
Thyroid disease
Testosterone secreting tumours
Congenital adrenal hyperplasia
Contraceptive pills (E.g. Depo-provera, Explanon, OCP)
What is meant by tubal disease?
Tubal diseases are conditions affecting the fallopian tubes
What are some clinical features of tubal disease?
- Abdominal or pelvis pain
- Vaginal discharge dyspareunia
- Cervical excitation menorrhagia
- Dysmenorrhoea
- Infertility
- Ectopic pregnancy
What are the 2 types of cause of tubal disease?
Infective
Non-infective
What are some infective causes of tubal disease?
- Pelvic inflammatory disease (Chlamydia, gonorrhoea, syphilis, TB)
- Transperitoneal spread (Appendicitis, intra-abdominal abscess)
- Infection following procedures (IUCD, hysteroscopy, HSG)
What are some non-infective causes of tubal disease?
- Endometriosis
- Surgical (Sterilisation, ectopic pregnancy)
- Fibroids
- Polyps
- Congenital
- Salpingitis isthmica nodosa (Diverticulosis of fallopian tubes)
What is endometriosis?
This is the presence of endometrial glands outside the uterine cavity
What are some factors that increase risk of endometriosis?
Retrograde menstruation
Altered immune function
Abnormal cellular adhesion molecules
Genetic factors
What are some symptoms of endometriosis?
- Dysmenorrhoea (Before menstruation)
- Dyspareunia
- Menorrhagia
- Painful defection
- Chronic pelvic pain
- Infertility
What will investigation show on endometriosis?
Investigation will show a fixed and retroverted uterus with characteristic chocolate cysts on the ovaries
What are some risk factors for male infertility?
Occupation
Smoking
Alcohol
Obesity
What are some pre-testicular causes of male infertility?
- Hypogonadism
- Hypothyroidism
- Diabetes
- Erectile dysfunction
What are some testicular causes of male infertility?
- Idiopathic
- Undescended testicles
- Urogenital infection
- Sexual factors
- Varicocele
- Torsion
What are the 2 categories of male infertility?
Obstructive
Non-destructive
How will obstructive male infertility present?
Obstructive infertility will present with normal testicular volume, normal secondary sexual characteristics but the vas deferens may be obstructed or absent
What are some endocrine features of obstructive male infertility?
- Normal LH
- Normal FSH
- Normal testosterone
How will non-obstructive male infertility present?
Non-obstructive infertility will present with low testicular volume and reduced secondary sexual characteristics
The vas deferens will be present and functional
What are some endocrine features of non-obstructive male infertility?
- High LH
- High FSH
- Low testosterone
What does examination of a female in infertility involve?
- General examination
- BMI testing
- Body hair distribution assessment
- Pelvic examination
- Assessing for pelvic tenderness and mobility
What are some investigations required in female infertility?
- HCG (Pregnancy) test
- Endocervical swab (For chlamydia)
- Cervical smear
- Blood testing (For rubella immunity)
- Mid-luteal progesterone level (7 days prior to expected period - Progesterone >30 is normal)
- Hysterosalpingiogram (HSG) tests tubal patency
- Laparoscopy
- Hysteroscopy
What condition is shown on this hysterosalpingiogram?
Bilateral hydrosalpinx
What is shown?
Tubal septum formation
What is shown?
Tubal polyp
What is involved in general examination of male infertility?
- General examination
- BMI measurement
- Assessment of testicular size and position
- Feel for presence of penile abnormalities, vas deferens and varicoceles
What is the initial test used in male infertility?
2 semen analyses, 6 weeks apart
What are normal test results in semen analysis?
- Volume >1.5ml
- pH 7.2 - 7.8
- Concentration >16 x 10^6
- Motility >30%
- Morphology >4%
- WBC < 1x10^6/ml
What tests are carried out if semen analysis is mildly abnormal?
LH
FSH
Testosterone
Prolactin
Thyroid hormones
What tests are carried out if semen analysis is severely abnormal?
Chromosomal analysis
CF screening
Testicular biopsy (may be required)
What tests can be used in cases of male genital abnormality?
Scrotal ultrasound
How often should intercourse be performed in conception?
Every 2-3 days, instead of timing intercourse with the menstrual cycle
What are some management options used in infertility management?
Treatment of the underlying cause
Vitamin supplementation
Lifestyle advice
Occasionally reproductive surgery
What vitamin supplements can be used in infertility?
Folic acid and vitamin D are the main 2 vitamin supplements usually required
In whom should folic acid be given to in infertility?
5mg OD folic acid should be given to women who are planning pregnancy or are in the early stages of pregnancy if they:
- (Or partner) Have a neural tube defects
- Have had a previous baby with neural tube defect
- (Or partner) Have a family history of neural tube defects
- Have diabetes
What dose of folic acid is given in pregnancy in most women?
400ug OD is given in pregnancy and throughout the 1st 12 weeks
What dose of vitamin D is given in pregnancy?
10ug OD
What are some indications for reproductive surgery?
- Pelvic adhesions
- Grade 1&2 endometriosis
- Chocolate cysts in ovary
- Tubal block
- Enhancement of IVF
