Infertility Flashcards
General recommendations to help fertility?
Preconceptional Supplements (folic acid and vitamin D)
Environmental factors (occupation/drugs)
Stop smoking
Females no alcohol, male limit alcohol
BMI - female <19 >30 is bad, male >30 is bad
How much sex to optimise fertility?
Every 2/3 days
Four types of infertility and their prevalence?
Anovulatory - 30%
Male factor - 35%
Tubal factor - 30%
Unexplained - 15%
Three types of anovulatory disorder?
Ovarian - PCOS, premature ovarian insufficiency
Pituitary - hyperprolactinaemia, hypopituitarism
Hypothalamic - hypogonadism
Causes of hypothalamic hypogonadism?
(Low FSH, v low LH, low oestrogen)
oWeight loss and over-exercise
o Systemic illness
o Idiopathic Hypogonadotropic hypogonadism
o Kallman’s syndrome – GnRH secreting neurones fail to develop.
What is GnRH level in hypopituitarism?
GnRH normal - can result from tumours, or infarction following Sheehan’s syndrome.
What do you do in hyperprolactinaemia?
(Reduces GnRH release –> Low FSH, low LH, Low oestrogen)
Give dopamine agonist
• 85% will get restored ovarian function
• 85% will conceive
• If cause is macroadenoma, 50% will concieve
Ways of detecting ovulation?
- Mid-luteal phase serum progesterone (standard test)
- USS follicular tracking (time-consuming)
- Temperature charts (not recommended)
- LH-based urine predictor kits (ovulation should follow LH surge)
3 groups of ovulatory disorder?
- Group I: hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism).
- Group II: hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome).
- Group III: ovarian failure.
Clinical features of Group 1
(Hypogonadotrophic/ Hypothalamic hypogonadism)?
- Low energy availability/ eating disorders
- Low bone mass
- Menstrual disturbance
(Female athlete triad)
Hormone levels in Group 1 disorder?
Oestrogen = Low FSH = low/ normal
Management of group 1 disorder?
If BMI <19 – increase weight.
If high exercise levels – moderate exercise.
Gonadotrophins for ovulation induction.
Clinical features of group 2 (PCOS)?
- Polycystic ovaries on USS
- Clinical/biochemical hyperandrogenism
- Oligo/anovulation
(Rotterdam criteria)
At increased risk of developing hypertension, diabetes and sleep apnoea later in life.
Hormone levels in PCOS?
Oestrogen = Low FSH = low/ normal Oestrogen = normal FSH = normal
Management of PCOS?
Clomifene
Metformin
Gonadotrophins
Ovarian diathermy
What is clomifene?
- 1st line in PCOS – oestrogen receptor blocker –> increases FSH/LH (fools pituitary into thinking there is no oestrogen) – given from day 2 to day 6. Limited to 6 months’ use.
- Multiple pregnancy more likely
Which two treatments for PCOS make multiple pregnnacy more likely/
Clomifene
Gonadotrophins
Clinical features of group 3 (premature ovarian insufficiency)?
- Oligo/amenorrhoea for at least 4 months
- Elevated FSH level >25 IU/L on two occasions >4 weeks apart
- Low oestrogen (vasomotor symptoms, osteoporosis)
(Loss of ovarian activity before 40 years)
Hormone levels in group 3 (premature ovarian insufficiency)?
Oestrogen = low FSH = high
Tests in group 3 disorders?
Karyotype – Turner Syndrome (45X) –> Refer to endocrinologist, cardiologist and geneticist
Karyotype – Chromosomal Material –>Discuss gonadectomy
Fragile X –> Refer to geneticist (Implication to family members)
Anti-adrenal antibodies –> Refer to endocrinologist
Thyroid peroxidase antibodies –> Test TSH every year
Fertility treatment for premature ovarian failure/
Fertility Treatment • Oocyte donation • No interventions shown to increase ovarian activity and natural conception rates . Hormone replacement therapy
What is ovulation induction?
• Aim – unifollicular growth
o Timed with urinary LH/hCG administration
o Timed sexual intercourse.
Risk factors for primary ovarian insufficiency?
• Modifiable Risk Factors
o Gynae surgical practice
o Stop smoking
o Modified treatment regimens.
• Non-modifiable risk factors o Chromosomal (e.g. Turner’s XO) o Fragile X o FNA e.g. BPES o Adrenocortical/thyroid antibodies o Idiopathic
Consequences of premature ovarian insufficiency?
Reduced life expectance due to cardiovascular disease
Atherosclerosis
Turner’s associated with congenital DVS
Decreased bone mineral density
No oestrogen – need DEXA scan, healthy lifestyle and vitamin D
Can give HRT – you are supplementing what isn’t there so is not dangerous.
Fertility – small chance of pregnancy – need contraception
Types of male factor infertility
- Oligozoospermia = <15 million sperm
- Asthenzoospermia = reduced sperm motility
- Teratozoospermia = abnormal sperm morphology
Causes of male factor infertility?
Most causes not reversible
o Idiopathic (most common cause)
o Hypogonadism (10%)
o Genetic causes (Needs to be excluded before ICSI) - CF
o Testicular trauma / surgery / developmental abnormalities (cryptorchidism)
o Obstructive (surgery – vasectomy / infection)
o Anabolic steroid induced (not always be reversible)
o Previous chemotherapy / radiation
What is the only medically treatable cause of male factor infertility?
Hypogonadism (low FSH/LH)
Stop drugs – anabolic steroids most common cause.
• No guarantee it will come back
Treat hyperprolactinaemia
Pulsatile gonadotrophing and hCG
Testosterone alone will not induce spermatogenesis
• Must have LH and FSH
Causes of tubal factor infertility?
o PID (chlamydia) o Endometriosis o Past abdominal/pelvic infection or surgery (appendicitis) o Treatment to cervix o Fibroids/polyps
Investigations in tubal factor infertility?
o Hysterosalpingography
Appropriate for low risk women
o Hysterosalpingo-contrast-ultrasonography
Alternative to HSG with no radiation exposure
o Laparoscopy
The gold standard
o Always screen for chlamydia and other pathogens before test.
When is IVF recommended?
If all other causes are excluded, IVF is recommended after two years of trying.
What is intrauterine insemination?
o Follicle development tracked ultrasonographically
o Sperm prepared
o Placed in uterine cavity with USS
What is the aim of IVF?
oAim for: controlled multi-follicular growth
What is the process for IVF?
Hormones (gonadotrophins) taken by the woman as injections cause the ovary to make several eggs at the same time (multifollicular recruitment)
Egg collection 36 hours later (Sedated transvaginal procedure)
Oocytes and sperm incubated together overnight
• The fertilised eggs (embryos) grow under observation in the laboratory for two to six days
• Selection process - to identify embryo(s) with the best chance of continuing to develop into a baby
Embryo transfer to uterus (like a smear test)
Give woman progesterone for luteal support
Pregnancy test 2 weeks after transfer to see if successful
First pregnancy ultrasound scan is performed 3 weeks later.
What is intracytoplasmic sperm injection?
o Similar protocol to IVF
o Indicated in severe MF infertility
o Single sperm injected into denuded oocyte.
Dangers of fertility treatment?
Ovarian hyperstimulation syndrome (OHSS)
Multiple pregnancy
What is OHSS?
Iatrogenic process
Vasoactive product released from ovaries
Increased capillary permeability, fluid accumulation in the abdomen and severe dehydration due to loss of vascular fluid – LIFE THREATENING.
Young, PCOS, pregnant
Options for fertility preservation in men?
• Advisable prior to any therapy that potentially affects fertility - Chemotherapy, Radiotherapy, Surgery (Testicular, Reproductive tract, Retroperitoneal nerve plexus (para-aortic node dissection))
• Postpubertal boys and adults
o Sperm cryopreservation
• Prepubertal boys (currently no clinically available option)
Options for fertility preservation in women?
• GnRH analogues for ovarian suppression
o Encouraging evidence from trials on women having chemotherapy for breast cancer
o No clear evidence on other cancers – can try empirically
• Oocyte / embryo cryopreservation
o Reproductive autonomy vs freeze-thaw survival
• Social egg freezing/ anticipation of age-related decline in fertility
