Infertility Flashcards by Jack Molyneux

What percentage of couples suffering from infertility will conceive spontaneously or with relatively simple advice?

50%

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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

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What percentage of couples conceive within 6 months of trying?

75%

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What percentage of couples conceive within 12 months of trying?

90%

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What percentage of couples conceive within 24 months of trying?

2 years

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How long after attempted conception is IVF offered by NHS Scotland?

2 years

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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

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What is meant by primary infertility?

The couple has never concieved before

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What is meant by secondary infertility?

The couple has previously conceived, although this may not have been successful (e.g. miscarriage, ectopic pregnancy)

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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

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What are some causes of infertility in females?

Tubal disease
Fibroids
Endometriosis/adenomyosis
Weight
Age
Ovulatory disorders (Causing anovulatory infertility)

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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)

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What is meant by tubal disease?

Tubal diseases are conditions affecting the fallopian tubes

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What are some clinical features of tubal disease?

Abdominal or pelvis pain
Vaginal discharge dyspareunia
Cervical excitation menorrhagia
Dysmenorrhoea
Infertility
Ectopic pregnancy

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What are the 2 types of cause of tubal disease?

Infective
Non-infective

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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)

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What are some non-infective causes of tubal disease?

Endometriosis
Surgical (Sterilisation, ectopic pregnancy)
Fibroids
Polyps
Congenital
Salpingitis isthmica nodosa (Diverticulosis of fallopian tubes)

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What is endometriosis?

This is the presence of endometrial glands outside the uterine cavity

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What are some factors that increase risk of endometriosis?

Retrograde menstruation
Altered immune function
Abnormal cellular adhesion molecules
Genetic factors

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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