Infertility Flashcards
What is infertility?
Inability to conceive despite regular unprotected intercourse
How many couples report infertility problems?
1 in 7
When should infertility be investigated?
Should be investigated after 1 year of trying to get pregnant
What percentage of couples will conceive within 24 months?
95%
What things are investigated in infertility?
Are there eggs
Are there sperm
Can they meet
What are the important aspects of the female partner’s history in infertility?
Duration of infertility Previous contraception Fertility in previous relationships Previous pregnancies and complications Menstrual history - most important features as this will tell you if there are eggs being released, also ask about pain Medical and surgical history Sexual history Previous investigations Psychological assessment
What are the important aspects of the physical examination of the female partner?
Weight
Height
BMI
Fat and hair distribution
Galactorrhoea
Abdominal examination
Pelvic examination
What causes hirsutism?
Testosterone excess
What hormones cause androgen excess?
Testosterone Androstenedione Dehydroepiandrosterone (DHA) Dehydroepiandrosterone sulphate (DHAS) 17-OH progesterone Sex hormone binding globulin
What is used in the clinical measurement of androgen excess?
Ferriman Gallwey score
What is acanthuses nigricans a sign of?
Polycystic ovarian syndrome
What might galactorrhea indicate?
Prolactinoma
What are the important features of the pelvic examination of the female partner/what are you looking for?
Masses Pelvic distortion Fixed retroversion Tenderness Fibroids - pressure symptoms, period problems, infertility
What are the important aspects of the male partner’s history?
Previous fertility Medical history Surgical history Occupational history Sexual history Previous investigations and treatments
What are the important aspects of the physical examination of the male partner?
Weight
Height
BMI
Fat and hair distribution
Abdominal and inguinal examination
Genital examination
What might you be looking for in the genital examination of the male partner of a couple reporting infertility?
Epididymitis - STDs, NSTD
Testicular size - Klinefelter’s syndrome
Vas deferens - cystic fibrosis mutations and congenital bilateral absence of the vas deferent
Testicular maldescent
Varicocoele
What do home ovulation kits measure, how does this compare to measurement in clinic?
Home ovulation kits measure LH surge, in clinic progesterone is measured as this has a longer peak (mid-luteal progesterone)
When should a couple be referred for investigation of infertility?
1 year of trying (unless there’s a problem e.g. period irregularity, PMH, testicular problems)
Abnormal tests
HIV/Hep B
Anxiety
Age
< 35 years after 1 year
35-45 years after 6 months
> 45 years little can be offered
What are the baseline investigations of a couple reporting infertility?
Female partner;
- rubella immunity
- chlamydia
- TSH
- if periods are regular measure mid-luteal progesterone
- if periods are irregular do day 1-5 FSH, LH, prolactin, TSH and testosterone
Male partner;
- semen analysis
What investigations are done at a fertility clinic?
Pelvic ultrasound Physical examination Further investigations Semen analysis repeat if required Tubal potency test - tested by x-ray, HyCoSy or laparoscopy
(HyCoSy = hysterosalpingo-contrast-sonography)
What are the features of polycystic ovary syndrome?
Diagnosis of exclusion in infertility - only made when other diagnoses of hyperandrogegism have been ruled out
2 of the following 3 features must be present to have PCOS;
- androgen excess (clinical e.g. hirsutism, biochemical e.g. testosterone)
- infrequent periods (anovulation)
- polycystic ovaries on ultrasound
How many women have polycystic ovaries?
1 in 5
What are the treatment options for ovulatory disorders?
Treat underlying cause e.g. hormonal imbalance
Weight loss/gain
Achieve BMI > 18 and < 35
Ovulation induction
What must be working in order to induce ovulation?
Hypothalamic-pituitary axis
How is ovulation induced?
Clomifene given if hypothalamic-pituitary axis is working, this stimulates GnRH -> FSH and LH -> oestrogen and progesterone
If the axis is not working, gonadotrophins are given to directly stimulate oestrogen and progesterone
What is clomifene?
Selective oestrogen receptor modulator
What is the dose of clomifene used for ovulation induction?
50-150mg days 2-6, progesterone priming if amenorrhoea
How is clomifene use monitored?
Follicle scanning in first cycle - 15% require dose adjustment
Only prescribed by hospital (not GP) due to monitoring need
What are the side effects of clomifene?
Vasomotor
Visual
When are gonadotrophins used in ovulation induction?
No ovulation with clomifene
Ovulation but no pregnancy
What causes side effects of gonadotrophins?
Multiple pregnancy and multi-follicular response causing ovarian hyperstimulation side effects
How many cycles of gonadotrophins can be given?
3-6
What are the treatment options for infertility due to a tubal factor or endometriosis?
Surgical vs medical treatment for endometriosis or fibroids
Reversal of sterilisation (no longer available on NHS)
IVF or tubal surgery
What are the treatment options for an infertile male?
Urologist appointment if appropriate IVF/ICSI Intra-uterine insemination Surgery - reversal of vasectomy (not available on NHS) or surgical sperm retrieval Donor insemination
What are the causes of azoospermia?
Post-testicular
- obstruction
- iatrogenic
- congenital
- infective
Testicular
- normo-gonadotrophic
- hypo-monadism
- hyper-gonadotrophic e.g. Klinefelter’s
What is involved in the investigation of azoospermia?
History Examination FSH LH Testosterone Karyotype PRL CF screen
What are the modes of surgical sperm retrieval?
Micro-epididymal sperm aspiration
Testicular sperm extraction
What are the treatment options for sexual problems causing infertility?
Psychosocial counselling
Artificial insemination - timed insemination at home or intra-uterine insemination at clinic
What are important factors when investigating unexplained infertility?
Consider IVF option if problems have been ruled out
Age
Previous pregnancy
Duration of infertility
What is involved in IVF treatment?
Eggs harvested from ovary Eggs fertilised in the lab with sperm Embryos undergo a number of cell divisions Embryo transferred into the womb Heavily regulated treatment
How many cycles of IVF are done per year, and how many IVF births are there per year?
60,000 cycles
12,000 births (nearly 2% of total UK births)
What is involved in intracytoplasmic sperm injection?
Injection of mature eggs with a single sperm
Incubation overnight
Live birth rate following IVF decreases with what?
Increasing female age
