Infertility Flashcards
Epidemiology of infertility
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
What are the top causes of infertility
- Unexplained 25%
- Ovulatory 25%
- Tubal 20%
- Uterine / peritoneal 10%
- Male 30%
What do the population trends show about fertility?
Ave age first birth 28.5
First time more babies born to >35 than <25
Link between miscarriage and age
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
What are the principles of care for infertility?
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
Initial advice to give when tackling infertility?
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
What is the criteria for early referral for females?
- Female
- Age > 35
- Menstrual disorder
- Previous abdominal / pelvic surgery
- Previous PID / STD
- Abnormal pelvic examination
What is the criteria for early referral in males?
Previous genital pathology
Previous urogenital surgery
Previous STD
Systemic Illness
Abnormal genital examination
What is some good advice for preconception?
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)
What are some reproductive disorders associated with obesity?
PCOS
MISCARRIAGE
INFERTILITY
OBSTETRIC COMPLICATIONS
Lower ART success
Obesity and infertility
- 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
Investigations for infertility
- Ovulation / ovarian function / ovarian reserve
- Semen Quality
- Tubal Patency (+ Uterus)
How do we check ovulation?
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
How do we carry out ovarian reserve testing?
- 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
How do we carry out male semen investigations?
Semen Analysis
WHO (2010) methodology
- Count (>15m/ml)
- Motility (>32%)
- Morphology (>4%)
- Total >7.5m
Repeat if abnormal
Anti-sperm Antibodies – not required
When should we refer to NHS fertility clinic?
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
What are some further investigations for male infertility?
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
Tubal patency/ anatomy
Tubal Patency testing
Low risk
Hysterosalpingogram (HSG)
HyCoSy
High risk
When pathology suspected
STI, PID
Pain
Previous surgery
Laparoscopy + dye
USS
Swabs before instrumentation
What are some treatments for male infertility?
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
What are some social issues in male that can cause infertility?
Heat - occupation
Underpants / boxers ?
Smoking
Alcohol
Occupational exposure
Diet / Supplements
Folic acid (5mg) and Zinc (55mg)
? Vitamin E / selenium
Weight
Infertility and WHO Group 1 (Low FSH/LH/E2
Stress
Weight loss
Exercise
Kallman’s
Treatments
FSH+LH
GnRH pump
Normalise weight
Endocrine causes of infertility
Thyroid
Adrenal
Adenoma – Prolactin – Tx Bromocriptine
Sheehan’s – Treatment - FSH+LH
PCOS and infertility
Normal FSH, USS, androgens
85% of causes
Treatment – Ovulation Induction (Clomifene
Menopause and infertility
High FSH
Treatment - Donor Egg
PCOS features
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)
Treatment for PCOS
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
What are some further management of certain ovulatory disorders such as PCOS?
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)
Laparoscopic ovarian drilling
- 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%
Sites and causes of Tubal disease?
Sites
Proximal
Distal
Hydrosalpinx
Adhesions
Ovarian
Tubal
Causes
Infections
- Chlamydia
- Gonorrhoea
Endometriosis
Surgical
- Adhesions
- Sterilisation
What are the treatment options for tubal disease?
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%
What is the medical treatment of endometriosis?
Medical treatment of minimal or mild endometriosis does not improve chances of pregnancy
What are the surgeries used for mild endometriosis?
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
What are the features of unexplained infertility?
- 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
Treatment of Unexplained Infertility
Clomiphene
Not recommended in NICE 2013
SIUI
Not recommended in NICE 2013
IVF
Recommended after 2 years infertility
What are the types of assisted conception?
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
What are some embryo transfer strategies
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
What are the risks of IVF?
Multiple Pregnancy
Miscarriage
Ectopic
Fetal abnormality?
Ovarian Hyperstimulation Syndrome (OHSS) 1-5% (lower @JW)
Egg Collection (1:2000)
Longer term - ? Ovarian Ca
What are the patient factors that affect success?
- Age
- Cause of Infertility
- Previous Pregnancies
- Duration of Infertility
- Number of Previous attempts
- Specific medical conditions
- Environmental factors
What are the maternal risks as age increases?
- Increased risks of
- Hypertension
- Diabetes
- IUGR
- Operative delivery
- Thromboembolism
- Maternal death
What are some uterine abnormalities?
Associations with infertility / miscarriage
Exact role is not clear
Abnormalities
- Adhesions
- Polyps
- Fibroids
- Septate Uterus
Site of fibroids & IVF impact
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
Features of myomectomy
Pregnancy rate following myomectomy higher when compared with women with untreated myomas
42% vs 25%
No RCTs – further research needed
Examples of intrauterine adhesions
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
What are some Mullerian abnormalities
Normal uterus
Dysmorphic uterus
Septate uterus
Bicorporeal uterus
Hemi uterus
Aplastic uterus
What is a septate uterus?
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
Access to IVF according to NICE 2013
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
