Infertility Flashcards
Components of female fertility history?
- Age
- Development
- Menstrual cycle
- Pregnancies
- Time trying to conceive
- Previous contraception
- Stigmata endometriosis
- Sexual patterns
- Med / surg / psych
- Family
Components of male fertility history?
- Age
- Past fertility
- Development
- Sexual function
- Testicular: trauma, descent, torsion
- Med / surg / psych
- Family
- Vasectomy
What are the broad components of infertility investigation?
- Hormones
- Genetics
- Imaging
- Screening
- Semen analysis
What is the reproductive age range?
15-44 years approx
What is infertility?
Failure of couple to conceive after 12 months of frequent, unprotected intercourse
What is the series of events broadly required for conception?
1) - Ovulation of competent oocyte
2) - Production of competent sperm
3) - Juxtaposition of sperm and oocyte in a patent reproductive tract and subsequent fertilisation
4) - Generation of a viable embryo
5) - Transport of embryo into uterine cavity
6) - Successful implantation of the embryo into the endometrium
How does progesterone secretion relate to the menstrual cycle and conception?
Secretion of progesterone by the corpus luteum dominates the luteal phase of the menstrual cycle and persists if conception occurs
What does progesterone do to the cervical mucous?
Acts on endocervix to convert thin, clear cervical mucous into sticky mucoid material
What does progesterone do to basal body temperature?
Changes thermoregulatory set point resulting in basal body temp rise
Which tests provide indirect evidence of ovulation and timing?
- Basal body temp
- LH urine kits
What is the initial evaluation for ovulation?
- Hx and PEx
- Basal body temp charting
- Ovulation predictor kits
What are the further evaluations for ovulation?
- Mid luteal phase progesterone level
- Ultrasonography
- Endometrial biopsy (not routine)
What are the initial and further evaluation investigations for the uterus?
Initial: US Further: -saline infusion ultrasonography -Hysterosalpingography -MRI -Hysteroscopy
Initial evaluation of male infertility?
- Semen analysis
- Repeat if indicated
- Postcoital test (not routine)
When is uterus assessment particularly important in infertility work up?
Uterine abnormalities usually cause pregnancy loss. Important to assess if:
- abnormal bleeding
- pregnancy loss
- preterm delivery
- previous uterine surgery
What are the important characteristics of a normal hysterosalpingography (HSG)?
- Uterine cavity smooth and symmetrical (indentations / irregularities suggest leiomyomas, polyps, adhesions)
- Proximal 2/3 fallopian tube thin (~ diameter of pencil lead)
- Distal third = ampulla; dilated cf proximal portion of tube
- Free spill of dye from fimbriae outlining bowel etc in pelvic cavity
Causes of pelvic adhesions
- infection (PID, appendicitis)
- endometriosis
- abdominal / pelvic surgery
How should semen analysis be collected and performed?
- Obtained by masturbation after 2-3 days of abstinence
- Analyse within 1h
- Evaluate quantity and quality of seminal fluid, sperm concentration, sperm motility and morphology
What are the groups of male factor infertility aetiology?
- Hypothalamic pituitary disease causing gonadal dysfunction
- testicular disease
- post testicular defects impeding disorders of transport or ejaculation
- unexplained
How long does sperm production and development take?
~70 days
When should endocrine evaluation be undertaken in male factor infertility investigation?
Individuals with abnormal sperm concentrations or signs of androgen deficiency
How can primary and secondary hypogonadism be detected?
Serum FSH, LH and testosterone
- Primary: low testosterone, elevated FSH / LH
- Secondary: low testosterone, FSH and LH
What is the hormone pattern in exogenous steroid use?
Low LH in presence of oligospermia and normal testosterone level
What should be assessed in men with low serum testosterone?
Serum prolactin
When is genetic testing indicated for sperm?
Azoospermia or severe oligospermia
What are the most common genetic abnormalities producing decreased sperm count?
- CFTR (Cystic fibrosis)
- Somatic and sex Chr abnormalities
- microdeletions of Y chromosome
When is ovulation stimulation indicated? What must be done first
Women with anovulation or oligo-ovulation.
BUT
any identified condition a/w ovulatory disorders should be treated before initiating ovulation induction therapy (e.g. thyroid disorders, PCOS, high stress)
What is the medication commonly used for ovulation induction?
Clomiphene citrate:
- SERM competitively inhibits oestrogen binding to oestrogen receptors at hypothalamus and pituitary
- causes gonadotropin release from pituitary stimulating follicle development in ovaries
How is clomiphene administered?
Daily for 5 days in the follicular phase of the menstrual cycle starting between days 3-5
What are the risks of clomiphene?
- Multigestation 10% (usually twins)
- Ovarian hyper stimulation and cyst formation
What is controlled ovarian hyper stimulation?
Exogenous gonadotropins given to stimulate follicular development. Aims to achieve mono follicular ovulation in anovulatory women. Can be purified human or recombinant FSH, LH.
How is IUI conducted?
- Ejaculated semen washed to remove bacteria, PGs, proteins
- Sperm suspended in medium
- Speculum inserted into vagina
- Specimen placed into thin flexible catheter which is advanced through the cervix
What is ART?
All fertility procedures involving the manipulation of gametes, zygotes, or embryos to achieve conception
What is the process of IVF?
- Ovarian stimulation to produce multiple follicles
- Retrieval of oocytes from ovaries
- Oocyte fertilisation in vitro in lab
- Embryo incubation in lab
- Transfer of embryo to uterus via cervix
What are the medications required for IVF?
- Gonadotropins to stimulate follicle development
- Gonadotropin releasing hormone analogue (agonist or antagonist) to prevent premature ovulation during follicle development
- hCG to initiate final maturation of oocytes prior to their retrieval
- Progesterone to ensure endometrial secretory changes and support potential pregnancy
What are the indications for IVF?
- Absent / blocked FTs
- Tubal sterilisation
- Failed surgery to achieve tubal potency
- Severe pelvic adhesions
- Severe endometriosis
- Poor ovarian response to stimulation
- Oligo ovulation
- Severe male factor infertility
- Unexplained infertility
- Failure with more conservative treatments
