Infertility Flashcards
Define infertility
Disease of the male or female reproductive system defined by failure to achieve pregnancy after 12 months or more of regular, timely sexual intercourse.
It can be classified as primary where there is an inability to have a pregnancy, or secondary where there is an inability to have a pregnancy after a previous successful conception
What RF are associated with male infertility
What RFs are associated with female infertility
Male:
1) Medications
2) Medical hx or orchitis or crypto-orchidism (testicular pathology)
3) Inguinal/testicular surgery
4) Sedentary lifestyle
5) Heat-generating => Cycling, tight boxers
6) Environmental: Smoking, Drug use
7) Premature ejaculation
Female:
1) Weight & Age: Declines with increasing weight and age (due to irregularities in ovulation and increased proportion of abnormal oocytes)
2) Anovulation/oligo-ovulation: PCOS, Hyperprolactinemia, Hyper/hypothyroidism
3) Pelvic pathology: PID, surgery, congenital anomalies (e.g. Mullerian)
4) Unexplained
Both: Timing and frequency of sexual intercourse, knowledge of human reproduction (oocyte most receptive within 24 hours from ovulation)
What are the normal values of Semen Analysis?
a) Volume (2-6ml)
b) Concentration (>15 million)
c) Motility (>40%)
d) Morphology (>4% normal)
e) Anti-sperm antibodies
Give common causes of azoospermia
Pre-testicular: Genetic abnormalities, hormonal imbalances, CF
Testicular: Orchitis, crypto-orchidism, varicocele, trauma, radiation therapy
Post-testicular: vasectomy, congenital absence of vas deferens, obstruction
When is progesterone taken in the investigation for infertility?
Progesterone is taken at day 21 of the cycle or 7 days before menses
What does the Anti-Mullerian hormone assess
assesses ovarian activity
What does the Hysterosalpingogram assess?
Assesses the contour of the endometrial cavity + patency of fallopian tubes
What is the gold standard for assessing pelvic structures
Laparoscopy, dye insufflation of tubes + Hysteroscopy
How would you investigate a couple presenting with infertility.
Detailed hx and exam
Male:
1) Semen Analysis: If abnormal, this is repeated in 3 months before moving on
a) Volume (2-6ml)
b) Concentration (>15 million)
c) Motility (>40%)
d) Morphology (>4% normal)
e) Anti-sperm antibodies
2) Further Testing: If oligo-azoospermia
a) Karyotype
b) y-microdeletion studies
c) CF screen (Azoospermia)
d) Full hormone profile (FSH, LH, Testosterone, TFTs
3) DNA fragmentation studies
Female:
1) Full hormone profile: (Pre-ovarian)
a) FSH, LH, E2 taken at 3rd day of menstrual cycle
b) Progesterone is taken at day 21 of the cycle or 7 days before menses
c) Prolactin and TFTs (If androgenic, add testosterone, DHEA, free androgen index)
2) Anti-Mullerian hormone (assesses ovarian activity) (ovarian)
Post-Ovarian
3) Hysterosalpingogram (Assesses the contour of the endometrial cavity + patency of fallopian tubes)
4) Assess pelvic structures (Laparoscopy, dye insufflation of tubes + Hysteroscopy)
If you are explaining to a couple when they should have sexual intercourse, what will you tell them?
14 days before the start of the women’s period
How do you track ovulation?
Day-21 progesterone
US tracking of follicle
How would you manage infertility?
Conservative management:
- Encourage a healthy lifestyle (reduce smoking, BMI)
- Frequent sexual intercourse (3-4/week) esp. during mid-cycle
- Daily folic acid (0.4mg/day or 5mg if diabetic or obese)
- Anti-oxidant vitamin E for males
If anovulation: Ovulation induction (Clomiphene citrate, letrozole, FSH) with ultrasound tracking of follicle. hcg may be used to trigger ovulation if follicle>18mm on US
If tubal -> Adhesion -> Adhesiolysis
If endometriosis -> Laparoscopic coagulation/excision
ART - Assisted reproductive techniques
What are the risks of ovulation induction?
Multiple pregnancy
OHSS
Premature ovarian insufficiency
What are examples of ART?
Donor oocytes, sperm, gamete, embryo
IVF
ICSI
(Just dont say intrauterine insemination)
Define and Explain the process of Intrauterine insemination
Success rate
It is the timed introduction of sperm into the uterine cavity
Highly motile sperm are extracted from a sample following preparation in a culture medium. These sperm are then introducted directly into the uterine cavity via a Fine Plastic Catheter! and aligned with natural ovulation or in conjunction with induction
Success rate = 20% per cycle
What is IVF briefly?
What is the success rate?
Artificial reproductive technologies. Sperm and oocytes are mixed outside the cavity => In-vitro fertilization before the resulting embryo being transferred into the cavity and the rest are cryopreserved. The process involves ovarian stimulation, oocyte retrieval, insemination, embryo transfer and luteal support
Success is based on age: >50% in <35, 20% at 40
What is ICSI?
Intracytoplasmic sperm injection (Best for male infertility)
The process involves ovarian stimulation, oocyte retrieval, insemination, embryo transfer and luteal support. Here, insemination involves the direct injection of a single sperm into an oocyte and the resulting embryo is transferred into the uterus
What are the complications of ART?
Multiple pregnancy
Ovarian Hyperstimulation syndrome
What is OHSS and explain the pathophysiology of it
Ovarian hyperstimulation syndrome is a life-threatening complication of ovulation induction which is precipitated by hcg administration. VEGF mediates this syndrome and is characterized by increased vascular permeability => leakage leading to
1) Ascites, pleural effusion (Can add to pre-eclampsia, ovarian pathology, and HF)
2) Pre-renal failure
3) Torsion
What are the risk factors for OHSS?
Think what makes the dose appear more effective?
1) reduced BMI (higher dose/kg)
2) PCOS (ovaries already big)
3) Age <30 (more receptive)
4) Previous OHSS
5) Increased Oestrogen levels
What symptoms are associated with OHSS in increasing severity
1) Abdominal pain (increasing with severity) eventually torsion
2) Nausea and vomiting
3) Bloating -> Acites -> Hydrothorax (pleural effusion)
4) Ovarian size
5) Increased hematocrit >45%
6) Hypoproteinemia (pre-renal failure)
7) Oligo-anuria
8) ARDS
9) Thromboembolism (due to increased oestrogen)
How would you use the size of the ovaries to determine severity of condition?
Mild <8cm
Moderate: 8-12 cm
Severe: >12cm
What investigations would you perform?
How would you manage the patient?
History and Exam (abdominal pain, nausea/vomiting, Ascites, pleural effusion)
FBC (increased hematocrit, increased WCC)
U&E (Renal dysfunction/electrolyte disturbance)
Urinary catheter (Oliguria/anuria)
Imaging:
US -> Enlarged ovaries, Ovarian torsion
CXR -> Pleural effusion
Management:
1) Monitor signs and symptoms via investigations above
2) Urinary catheter insertion
3) Thromboembolism risk (TEDs, LMWH)
4) Drainage of ascites fluid (paracentesis) and hydrothorax (Thoracocentesis)
How would you prevent OHSS?
Monitoring follicles with US, discontinuing the cycle if concerning
What are the contraindications of COCP use?
What are the contraindications for progestogen-only?
Liver impairment, liver enzyme inhibitors, or hx of deranged LFTs
What are the advantages and disadvantages of COCP use?
