Infertility Flashcards
how are the psychological effects of fertility problems managed?
- inform that they may find a fertility support group helpful.
- a/v that stress in their relationship may reduce libido and frequency of intercourse, and that this may reduce fertility.
- offer counselling before, during and after investigation and treatment, and this should be by someone who is NOT directly involved in the management of the couple’s infertility problems.
effect of smoking on fertility?
women who smoke are likely to have reduced fertility, and should be offered r/f to a smoking cessation programme.
passive smoking is also likely to affect a woman’s chance of conceiving
smoking in men is associated with reduced semen quality, and stopping smoking will improve general health.
when should further assessment and investigation for infertility be offered to a woman and her partner who are trying to conceive?
if the woman if of reproductive age and has not conceived after 1 year of unprotected vaginal sexual intercourse, in the absence of any known cause of infertility.
after how many cycles of treatment should further assessment and investigation for infertility be offered to a woman trying to conceive using artificial insemination?
after 6 treatment cycles, in the absence of any known cause of infertility.
when is earlier r/f to a specialist indicated in infertility?
woman aged 36 or older
of known clinical cause of infertility or history of predisposing factors.
examples of disorders of ovulation that may be responsible for female infertility?
-PCOS-cause of hypothalamic-pituitary-ovarian dysfunction
-hypothalamic problems-excessive exercising, underweight. kallmann’s syndrome-congenital lack of hypothalamic prod. of GnRH, causes amenorrhoea and anosmia.
-pituitary problems-pituitary tumours-may destroy normal tissue-FSH and LH prod. usually 1st affected, may be panhypopituitarism=simmonds’ disease, hyperprolactinaemia-note prolactin can be increased with raised TRH prod. as occurs with hypothyroidism as TRH stimulates TSH AND prolactin release.
sheehan’s syndrome-anterior pituitary infarct following PPH
-thyroid disorders
-Cushing’s syndrome, CAH
-ovary problems-premature ovarian failure
chromosomal disorders-turner’s syndrome, testicular feminisation-androgen insensitivity, karyotype XXX-fertility often normal but may cause premature ovarian failure.
-chronic debilitating disease that may cause anovulation and amenorrhoea including uncontrolled diabetes, cancer, AIDs, end stage CKD and malabsorption.
f/u if 1st semen analysis is abnormal?
offer rpt confirmatory test, ideally 3mnths after initial to allow time for cycle of spermatozoa formation to be completed
BUT if gross spermatozoa deficiency then rpt test should be done as soon as possible.
what measures are used to predict likely ovarian response to gonadotropin stimulation in IVF?
- total antral follicle count
- anti-mullerian hormone-secreted by ovarian follicle cells
- FSH
at what stage of the menstrual cycle is a serum progesterone test offered in the investigation of female infertility?
day 21 of a 28 day cycle
or 7 days prior to 1st day of next predicted menstrual bleed, may need to be repeated weekly thereafter until next menstrual cycle starts.
test to see if pt ovulating
which women should be offered serum gonadotropin tests in investigation of infertility?
FSH and LH blood test in those with irregular menstrual cycles.
which women should be offered prolactin testing in investigation of inferility?
those with an ovulatory disorder, pituitary tumour or galactorrhoea.
problems of fallopian tubes, uterus or cervix that can cause female infertility?
- PID
- postpartum infection
- STIs
- previous pelvic surgery-adhesion formation
- Uterus and cervical adhesions-asherman’s syndrome-result of infection
- uterus deformity-septum or bicornuate uterus, may be more likely to cause recurrent miscarriage
- fibroids-causing significant uterine cavity distortion e.g. submucosal fibroids
- shortened/damaged cervix due to cone biopsy or cervical surgery
- endometriosis-tubal distortion and limitiation of fimbrial motility with adhesions
- previous sterilization
define primary amenorrhoea
failure of menses to occur by 16 years of age, in presence of normal growth and secondary sexual characteristics, or by 14 when no secondary sexual characteristics present.
define secondary amenorrhoea
absence of menstruation for at least 6 mnths in women with previously normal and regular menses, or for 12 mnths in those with previous oligomenorrhoea.
characteristic features of PCOS?
- irregular menses, oligomenorrhoea, amenorrhoea
- infertility
- features of hyperandrogenism-hirsutism, acne, male pattern alopecia
- obesity
- insulin resistance
causes of female infertility other than disorders of ovulation or tubal, uterine or cervical factors?
- drugs e.g. NSAIDs-inhibit ovulation, spironolactone-menstrual irregularities, neuroleptics, recreational e.g. cocaine, chemotherapy with cytotoxics-ovarian failure.
- occupation and environ exposure-pesticides, metals-lead, cadmium, and formaldehyde.
- stress
cause of excess androgen production by ovaries in PCOS?
increased LH and hyperinsulinaemia-occurs as a result of insulin resistance, and this resistance becomes worse with weight gain
note that insulin inhibits hepatic production of sex hormone binding globulin, so although total testosterone may be normal or only modestly increased, free unbound testosterone is elevated
increase LH concentration relative to FSH switches ovary production of oestrogens to androgens
why does endometrial hyperplasia occur in women with PCOS?
anovulatory cycles, so oestrogen produced as as ovarian follicle develops, but fails to rupture to cause corpus luteum production and progesterone production, so continued exposure to unopposed oestrogen
AND high androgen levels, testosterone converted to oestrogen in adipose tissue.
complications of PCOS?
infertility problems in pregnancy-gestational diabets, pregnancy induced HTN, pre-eclampsia, premature delivery, small for dates endometrial cancer type 2 DM and impaired glucose tolerance CVD dyslipidaemia sleep apnoea
investigations that could confirm PCOS diagnosis?
total testosterone-more than 5nmol/L
sex hormone binding globulin-normal or low
can then calculate free androgen index-would expect higher than normal (less than 5)
LH-may be elevated, increased LH:FSH, but this is not part of the diagnostic criteria
pelvic ultrasound
diagnostic criteria for PCOS?
2 of the following 3 criteria met:
- infrequent or no ovulation-oligo or amenorrhoea
- clinical or biochemical signs of hyperandrogenism e.g. hirsuitism, acne, male pattern alopecia, or elevated levels of total or free testosterone
- polycystic ovaries on US-12 or more follicles in at least 1 ovary, or increased ovarian volume (more than 10ml).
initial investigations in woman presenting with infertility?
- mid luteal serum progesterone-day 21 of 28 day cycle, or 7 days before predicted date of next bleed, to see if pt is ovulating
- LH and FSH-exclude premature ovarian failure and hypogonadotropic hypogonadism
- TSH-in those with thyroid symptoms
- prolactin-if ovulatory disorder, pituitary tumour or galactorrhoea, may be mildly elevated in PCOS
- screen for chlamydia
secondary care investigations of woman presenting with infertility?
hysterosalpingography or hysterosalpingo-contrast ultrasonography-screen for tubal occlusion in those not known to have comorbidities e.g. PID, prev ectopic or endometriosis.
if known comorbidites do laparoscopy and dye so tubal and other pelvic pathology can be assessed at the same time.
medical options for ovulation induction?
-clomiphene-binds to oestrogen receptors on hypothalamus inhibiting negative feedback of oestrogen to increase FSH release. given as 50 mg OD for 5 days, to be started within about 5 days of onset of menstruation (preferably on 2nd day) or at any time (normally preceded by a progestogen induced withdrawal bleed) if cycles have ceased, followed by 100 mg daily if required for a further 5 days, this second course may be given in absence of ovulation.
3 courses=adequate trial, should not be used for more than 6 cycles as possible increased risk of ovarian cancer.
-metformin
-or combination of the 2
-gonadotropins-if clomiphene resistant anovulatory infertility, but significant risk of multiple pregnancy.
-pulsatile GnRH and dopamine agonists-may be used in hyperprolactinaemia.
