Infertility Flashcards
what is a basic definition of infertility
the inability of a couple to conceive within 12 months without the use of contraception
what % of couples are able to conceive without problem
for those <40yrs:
80% will conceive within 1 year of trying
half of those who do not in the first year will in the second
how many couples experience problems with fertility
1 in 7
when should infertility be investigated
if after 1 year of trying there is no pregnancy
when should you potentially investigate fertility sooner
if there's a problem e.g. period irregularity past medical history testicular problems abnormal test results HIV/Hep B anxiety
age
<36 yrs after 1 year
35-45 years after 6 months
>45 yrs little can be offered
what are the three main queries when it comes to infertility
are there eggs available?
is there sperm available?
can they meet?
what should be covered in a female history for infertility
duration of infertility previous contraception fertility in previous relationships previous pregnancies/complications menstrual history medical/surgical history sexual history previous investigations psychological assessment
what should be covered in a female examination for infertility
weight height BMI (kg/m2) fat and hair distribution galactorrhoea abdominal examinaton pelvic examination
what are the implications of a higher BMI >30 on fertility/pregnancy
higher miscarriage rate
lower success of fertility treatment
higher medical complications e.g. HBP, diabetes
what does your BMI need to be to qualify for NHS fertility treatment
<30
what initial tests should be done for women first presenting with infertility problems
prolactin levels - prolactinaemia - if >1000 assess pituitary gland
androgen levels
- testosterone (T)
- androstendione
- dehydroepiandrosterone (DHA)
- dehydroepiandrosterone sulphate (DHAS)
- 17-OH progesterone
- Sex hormone binding globulin (SHBG)
how can hirsutism be measured clinically
look for hirsutism
ferriman gallwey score - from hair distribution on:
upper lips, chin, anterior chest, inner thigh, back
how is the ferriman gallwey score interpreted
Score <8 – no hirsutism
8-16 – mild
17-25 - moderate
>25 – severe
what are clinical signs of androgen excess
hirsutism
galactorrhoea
acanthosis nigricans
what should be looked for in a pelvic exam
masses/fibroids pelvic distortion fixed retroversion tenderness cervical abnormality vaginal septum
what are the complications of fibroids
pressure symptoms
period problems
infertility
what are the different kinds of fibroids
subserosal - outwith the lining of the muscles and uterine cavity - pressure symptoms, press on bladder, pain
intramural - if >1/2cm can interfere with implantation
submucosal - can interfere with implantation
what should be covered in a male history for infertility
Previous fertility
Medical history (mumps, testicular descent)
Surgical history
Occupational history
Sexual history (STD)
Previous investigations and treatment (varicocoele repair, vasectomy)
loss of body hair/less frequent shaving (less testosterone)
what should be covered in a male examination for infertility
weight height BMI (kg/m2) fat and hair distribution (hypoandrogenism) abdominal and inguinal examination genital examination
how can the male partners BMI affect fertility
high BMI can have a negative influence of spermatogenesis
what can examination of the epididymis show
epididymitis
STDs - chlamydia, gonorrhoea, NSTD
what can examination of testicular size show
klinefelter syndrome
hyperspermia
what can examination of the vas deferens show
possible CF - mutations and congenital bilateral absence of the vas deferens
NB if azoospermatic - indication to test for CF
what can examination of the testes show
testicular tumours
testicular maldescent
what is varicocoele and where is it more common
abnormla dilatio anf torsion of the veins in the scrotum
- more common on the left, anatomical drainage different as the they drain to the left renal vein instead of the IVC
what can examination of the penis show
hypospadias
how do you test for the availability of eggs
test serum progesterone in the mid-luteal phase of the cycle - day 21-28 to confirm ovulation if they have regular menstrual cycles
if irregular cycles - blood tests to measure serum gonadotrophins follicle stimulating hormone (FSH) and luteinising hormone (LH)
how do you test for the availability of sperm
computerised semen analysis
according to WHO what are the reference vakues of: semen volume sperm concetration total sperm number progressive motility total motility morphologically normal
1.5ml 15 million/ml 39 million 32% 40% 4%
what are the baseline investigations for a female partner investigating infertility
rubella immunity
chlamydia
TSH
if periods regular - mid-luteal progesterone (7 days prior to expected period)
if periods irregular - day 1-5 FSH, LH, PRL, TSH, testosterone
what are the baseline investigation for a male partner investigating infertility
semen analysis
what investigations can be done at the fertility clinical
pelvic ultrasounds physical exam further investigations semen analysis repeat if required tubal patency test
what is a HyCoSy and what is it used for
hysterosalpingo-contrast-sonography
small catheter though cervix then dye injected through
looks for patent tubes
what is laparoscopy used for
can assess tubal potency
diagnostic and therapautic to treat endometriosis
preferred for women with a higher tubal factor
what are the riss of laparotomy
risk of injury to bowel, bladder, ureter, thromboembolism
what is the difference between primary and secondary infertility
primary is couples who are struggling to conceive after 1 year with no previous pregnancies
secondary is couples who are struggling to convince after 1 year with at least one previous pregnancy i.e. were able to conceive before but not unable to
from most common to least common, what are the causes of primary infertility
ovulation problems
male - sperm problems
unexplained
tubal
from most common to least common, what are the causes of secondary infertility
tubal
ovulation problems
unexplained
male - sperm problems
what is polycystic ovary syndrome
set of symptoms due to elevated androgens in females
how can polycystic ovary syndrome be diagnosed
must beet 2 of the 3 criteria:
- androgen excess (clinical hirsutism, biochemical testosterone)
- infrequent periods (anovulation)
- polycystic ovaries (seen on underground
what defines a polycystic ovary
more than 12 follicles in one ovary
what are the three groups of causes for ovulatory disorders
- hypothalamic pituitary failure
- hypo-pituitary-ovarian failure
- ovarian failure
what is the treatment for ovulatory disorders
treat the underlying cause
weight loss/gain (BMI >18and <30)
ovulation induction
what are the three drugs used for ovulation induction
clomiphene (first line)
gonadotrophins
GnRH
what is clomiphene and how is it given
selective oestrogen receptor modulator
given 50mg-150mg day 2-6 of the cycle
if amenorrhoea - progestogen priming
NB does usually kept as low as possible to encourage only mono follicular development (higher % of conception)
how and why is clomiphene monitored
follicle scanning occurs in the 1st cycle
needed as 15% require a dose adjustment
what are the side effects of clomiphene
vasomotor
visual
how long can clomiphene be given for
6 cycles
when might gonadotrophin therapy be used
when no ovulation with clomiphene or ovulation but no pregnancy
how is gonadotrophin therapy given
FSH injection up to 3-6 cycles
what can be done if there is a tubal factor or endometriosis affecting fertility
some surgical or medical treatment for endometriosis and fibroids
consider IVF
what should a women with hydrasalpinges be offered before IVF and why
salpingectomy - fluid filled blocked tubes may cause further problems such as ectopic pregnancy
what treatment for infertility can males use
urologist appointment if appropriate IVF/ICSI intra-uterine insemination surgery (vasectomy reversal, surgical sperm retrieval) donor insemination
what is azoospermia
when semen contains no sperm
what are the types of azoospermia
testicular
- normogonadotrophic
- hypogonadotrophic
- hypergonadotrophic
post-testicular
- iatrogenic
- congenital
- infective
what are the investigations for azoospermia
history
examination
FSH, LH, testosterone, karyotype, PRL
CF screen
what is a possible treatment for azoospermia
surgical sperm retrieval
- micro-epididymal sperm aspiration
- testicular sperm extraction
what are some options for sexual problems that lead to infertility
psychosexual counselling - onward referral
artificial insemination - times at home, intra-uterine at clinic
what is the best course of action in treating unexplained infertility
IVF
don’t offer clomiphene
