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3A Womens health > Infertility > Flashcards

Infertility Flashcards

1
Q

Epidemiology of infertility

A

Failure to conceive after 1 year
Approx 15% (1:7) of couples
Up to 25% couples overall
Small increase in prevalence
Greater proportion of couples seek help
Considerable psychological distress

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2
Q

What are the top causes of infertility

A
  • Unexplained 25%
  • Ovulatory 25%
  • Tubal 20%
  • Uterine / peritoneal 10%
  • Male 30%
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3
Q

What do the population trends show about fertility?

A

Ave age first birth 28.5
First time more babies born to >35 than <25

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4
Q

Link between miscarriage and age

A

Likelihood of miscarriage increases from <35 to 35-40 and 40+
82.7% had chromosomal abnormalities, Brambati, 1990
+ Increased incidence of Downs
+ Increased maternal risks of pregnancy

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5
Q

What are the principles of care for infertility?

A

See both partners together
Explanation and written advice
Psychological effects of fertility problems
- Relationship difficulties (freq of SI)
- Support groups
- Counselling
Seen by specialist team
- improves effectiveness and efficiency of treatment & patient satisfaction with care

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6
Q

Initial advice to give when tackling infertility?

A

80% Couples (<40yrs) conceive in first year
Half of remaining will conceive in second year (CCR 90%)
Inform effect of age
Preconception advice
Refer after one year
Criteria for early referral
- Female age >35
- Known or suspected problem

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7
Q

What is the criteria for early referral for females?

A
  • Female
  • Age > 35
  • Menstrual disorder
  • Previous abdominal / pelvic surgery
  • Previous PID / STD
  • Abnormal pelvic examination
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8
Q

What is the criteria for early referral in males?

A

Previous genital pathology
Previous urogenital surgery
Previous STD
Systemic Illness
Abnormal genital examination

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9
Q

What is some good advice for preconception?

A

Intercourse – 2-3 x week
Folic acid – 0.4mg (5mg high risk)
Smear
Rubella
Smoking – cessation services
Pre-existing medical conditions
Drug history (prescribed / recreational)
Environmental / occupational exposure
Alcohol (women none)
Weight (BMI 19 – 30)

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10
Q

What are some reproductive disorders associated with obesity?

A

PCOS
MISCARRIAGE
INFERTILITY
OBSTETRIC COMPLICATIONS
Lower ART success

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11
Q

Obesity and infertility

A
  • BMI > 30 - longer to conceive
  • BMI > 30 - lower success with IVF
  • BMI and anovulation – losing weight improves chance
  • BFS advise inappropriate to treat if BMI >35
  • Men with BMI >30 reduced fertility
  • Group programmes more effective
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12
Q

Investigations for infertility

A
  • Ovulation / ovarian function / ovarian reserve
  • Semen Quality
  • Tubal Patency (+ Uterus)
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13
Q

How do we check ovulation?

A

Mid-luteal Progesterone
<16 anov
>16 < 30 equivocal
> 30 ovular
Series if long / irregular cycles

Don’t test
Temperature
LH urine testing
TFT’s, Prolactin (if ovulating)
Endometrial biopsy

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14
Q

How do we carry out ovarian reserve testing?

A
  • FSH (day2)
    >8.9 - low response
    <4 - high response
  • Antral Follicle Count (AFC)
    <4 - low response
    >16 - high response
  • Antimullerian Hormone (AMH)
    <5.4 - low response
    >25 - high response
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15
Q

How do we carry out male semen investigations?

A

Semen Analysis
WHO (2010) methodology
- Count (>15m/ml)
- Motility (>32%)
- Morphology (>4%)
- Total >7.5m
Repeat if abnormal
Anti-sperm Antibodies – not required

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16
Q

When should we refer to NHS fertility clinic?

A

Pathway agreed with Sheffield CCG
Referral after >1 year (sooner if indicated)
Initial investigations by GP
- Hormone profile (D2 FSH, D21 Prog)
- TFT, Prolactin – if indicated
- Rubella
- Smear
- Swabs
- Semen analysis
Pro-forma (couple) – Choose and Book
Seen in Dedicated fertility Clinic as couple

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17
Q

What are some further investigations for male infertility?

A

Interpret SA in light of history – illness, drugs etc
Clinical examination
- Secondary sexual characteristics
- Testicular size
Further tests (if Count <5m/ml)
- Endocrine (FSH, LH, Test, Prolactin)
- Karyotype (e.g. Klinefelters)
- Cystic Fibrosis Screen – link with CBAVD
Testicular biopsy (azoospermia)
- Only if cryopreservation facilities
Imaging – Vasogram, ultrasound, Urology

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18
Q

Tubal patency/ anatomy

A

Tubal Patency testing
Low risk
Hysterosalpingogram (HSG)
HyCoSy
High risk
When pathology suspected
STI, PID
Pain
Previous surgery
Laparoscopy + dye
USS

Swabs before instrumentation

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19
Q

What are some treatments for male infertility?

A

Mild - Intrauterine Insemination (IUI) - ?
Moderate abnormality - IVF
Severe – Intracytoplasmic Sperm Injection (ICSI)
Azoospermia
- Surgical Sperm Recovery
- Donor Insemination
Surgery
- Correction of epidymal block
- Vasectomy reversal
- Varicocele – no benefit
Hormonal
- Hypogonadotrophic hypogonadism - Gonadotrophins
- Hyperprolacinaemia - Bromocriptine with sexual dysfunction

20
Q

What are some social issues in male that can cause infertility?

A

Heat - occupation
Underpants / boxers ?
Smoking
Alcohol
Occupational exposure
Diet / Supplements
Folic acid (5mg) and Zinc (55mg)
? Vitamin E / selenium
Weight

21
Q

Infertility and WHO Group 1 (Low FSH/LH/E2

A

Stress
Weight loss
Exercise
Kallman’s

Treatments
FSH+LH
GnRH pump
Normalise weight

22
Q

Endocrine causes of infertility

A

Thyroid
Adrenal
Adenoma – Prolactin – Tx Bromocriptine
Sheehan’s – Treatment - FSH+LH

23
Q

PCOS and infertility

A

Normal FSH, USS, androgens
85% of causes
Treatment – Ovulation Induction (Clomifene

24
Q

Menopause and infertility

A

High FSH
Treatment - Donor Egg

25
Q

PCOS features

A

Rotterdam Criteria 2003 - 2 out of 3 criteria
Anovulation / oligo/amenorhoea
Polycystic ovaries on scan (TVS)
One ovary
>12 small follicles
Vol > 10cc
Raised Androgens
Clinical or biochemical
exclude adrenal cause)

26
Q

Treatment for PCOS

A

Normalise weight
Clomifene (or Tamoxifen)
Up to 6 cycles (NICE 2013)
Monitor (Progesterone & USS)
Inform of multiple preg rate (6-8%)
>12 months ? Ovarian Ca risk
Metformin
Less effective than clomifene alone
Less effective in obese
May help if clomifene resistant
GI side effects

27
Q

What are some further management of certain ovulatory disorders such as PCOS?

A

Clomifene / metformin resistant PCOS
Laparoscopic Ovarian Drilling
Gonadotrophin OvuIation Induction
Failure to conceive after 6 ovulatory CC cycles (New in NICE 2013)
Gonadotrophins (low dose step up, no agonist)
Multiple pregnancy (20%)
Monitoring
Ovarian Hyperstimulation Syndrome (OHSS)

28
Q

Laparoscopic ovarian drilling

A
  • Reproductive performance
  • 1/2 conceive in the first year
  • 1/3 continue to benefit for many years
  • Dec Miscarriage & recurrent miscarriage
  • Ovulation in 90%
  • Pregnancy in 70%
29
Q

Sites and causes of Tubal disease?

A

Sites
Proximal
Distal
Hydrosalpinx
Adhesions
Ovarian
Tubal

Causes
Infections
- Chlamydia
- Gonorrhoea
Endometriosis
Surgical
- Adhesions
- Sterilisation

30
Q

What are the treatment options for tubal disease?

A

Tubal Surgery (Laparotomy or Laparoscopy)
- Adhesiolysis - 40%
- Salpingostomy - 30%
- Proximal anastamosis - 30%
- Reversal of sterilisation - 60-80%
Tubal catheterisation
- Selective Salpingography - 21%
- Hysteroscopic - 49%
In vitro Fertilisation (IVF) – 30-40%

31
Q

What is the medical treatment of endometriosis?

A

Medical treatment of minimal or mild endometriosis does not improve chances of pregnancy

32
Q

What are the surgeries used for mild endometriosis?

A

Laparoscopic treatment
ablation or resection of minimal and mild disease
increases pregnancy and live birth rates
(OR 1.64; 95% CI 1.05 to 2.57).
Cochrane Database of Systematic Reviews 2003;1, 2003..

Laparoscopic cystectomy for endometrioma
increased pregnancy rates compared with drainage and coagulation

33
Q

What are the features of unexplained infertility?

A
  • Diagnosis of exclusion – 25%
  • Spontaneous cumulative pregnancy rate
    between 33% and 60% at 3 years
    Consider age and other factors
  • Treatment largely empirical
    Consider side effects and risks
34
Q

Treatment of Unexplained Infertility

A

Clomiphene
Not recommended in NICE 2013
SIUI
Not recommended in NICE 2013
IVF
Recommended after 2 years infertility

35
Q

What are the types of assisted conception?

A

Ovulation Induction (OI)
Stimulated Intrauterine Insemination (SIUI)
In Vitro Fertilisation (IVF)
- Intracytoplasmic Sperm Injection (ICSI)
- Surgical Sperm Recovery (PESA/TESE)
- Embryo Freezing
Donor Insemination
Donor Egg
Donor Embryo
Host Surrogacy

Everything below IVF is HFEA licensed

36
Q

What are some embryo transfer strategies

A

Current HFEA limit = 10%
Women < 37
- 1st cycle - 1 ET
- 2nd cycle – 1 ET if top quality embryos, 2ET if no top quality
3rd cycle 2ET
Women 37-39
- 1st and 2nd cycles - 1 ET if top quality embryos, 2ET if no top quality
- 3rd cycle 2ET
Women 40-42 – 2ET

37
Q

What are the risks of IVF?

A

Multiple Pregnancy
Miscarriage
Ectopic
Fetal abnormality?
Ovarian Hyperstimulation Syndrome (OHSS) 1-5% (lower @JW)
Egg Collection (1:2000)
Longer term - ? Ovarian Ca

38
Q

What are the patient factors that affect success?

A
  • Age
  • Cause of Infertility
  • Previous Pregnancies
  • Duration of Infertility
  • Number of Previous attempts
  • Specific medical conditions
  • Environmental factors
39
Q

What are the maternal risks as age increases?

A
  • Increased risks of
  • Hypertension
  • Diabetes
  • IUGR
  • Operative delivery
  • Thromboembolism
  • Maternal death
40
Q

What are some uterine abnormalities?

A

Associations with infertility / miscarriage
Exact role is not clear
Abnormalities
- Adhesions
- Polyps
- Fibroids
- Septate Uterus

41
Q

Site of fibroids & IVF impact

A

Intramural fibroids
reduced chance of pregnancy with ART
OR 0.46, 95% CI 0.24 to 0.88)

Submucous myoma
lower pregnancy rates
RR 0.30, 95% CI 0.13 to 0.70

42
Q

Features of myomectomy

A

Pregnancy rate following myomectomy higher when compared with women with untreated myomas
42% vs 25%

No RCTs – further research needed

43
Q

Examples of intrauterine adhesions

A

Rare
- may result from previous uterine evacuation or surgery
Associated with oligo-amenorrhoea

Hysteroscopic adhesiolysis
- restored normal menstrual pattern in 81%
- 63% conceived
- 37% delivered a viable infant

44
Q

What are some Mullerian abnormalities

A

Normal uterus
Dysmorphic uterus
Septate uterus
Bicorporeal uterus
Hemi uterus
Aplastic uterus

45
Q

What is a septate uterus?

A

Incidence not increased in infertilty
- 2-3% women
Associated with RPL and Preterm birth
Hysteroscopic metroplasty not shown to increase pregnancy rates
Further work required

46
Q

Access to IVF according to NICE 2013

A

Treat after 2 years or 12 months insemination
Discuss risks and benefits
Full cycle of treatment includes freezing
Women < 40 years
3 full cycles
Stop once age = 40
Women 40-42
1 full cycle (if no previous IVF, no low ovarian reserve)
Cancelled cycles don’t count (unless low ovarian reserve)
Private cycles count against total

47
Q
A

3A Womens health (33 decks)

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