Infertility Flashcards
Definition of infertility
Inability to conceive after 12 months of unprotected intercourse at least twice a week
Causes of infertility in order of prevalence
Male factors Unexplained Ovulation defects Tubal disease Endometriosis Other e.g previous pregnancy or surgery
Causes of ovulation defects
PCOS
Underweight
Hyperprolactinaemia
Ovarian failure e.g Turners, chemo
Most common cause of tubal disease
PID
Definition of unexplained infertility
Infertility with:
Patent Fallopian tubes
Ovulation
No sperm abnormalities
History for female
Age Primary or secondary infertility Menstrual history Gynae history Previous surgery PID
History for male
Medical history Previous surgery Previous infection - STI, mumps Sexual dysfunction - erectile and ejaculatory Alcohol Smoking
Examination for female
BMI
Secondary sexual characteristics
Hirsuitism
Galactorrhoea
Examination for male
Not essential if history doesn't suggest cause for infertility If possible, can check: Varicocele Testicle size Undescended testicles Chronic prostatitis
Baseline female investigations
Day 2 FSH and LH
Day 21 progesterone (can be difficult in oligomenorrhoea as need reading 1 week before menses which can be hard to predict)
Hysterosalpingography or diagnostic laparoscopy to test tubal patency
What do you see in a normal pelvic USS
Uterus is trilaminar - shows cavity is clear
Baseline male investigations
Analyse a sperm sample.
If abnormal analyse a second sample 3 months later.
What is an abnormal sperm sample
Count <15 million per ml
OR
Motility <40%
What additional male tests are required if abnormal sperm
Testosterone
FSH
LH
USS - prostate and seminal vesicles
What additional female tests are needed if baseline tests normal
Pelvic USS first. If US normal need: Hysteroscopy Prolactin Thyroid function tests Testosterone
Treatment for anovulation
Get BMI into 19-30 range
1st line: clomiphene citrate
2nd line: gonadotropins or GNRH analogues
3rd line: IVF
Bromocriptine if cause is hyperprolactinaemia
Treatment for tubal disease
Surgery
IVF
Treatment for male cause of infertility
IVF
Intracytoplasmic sperm injection
Evaluation of recurrent miscarriages
History and examination Bloods - TFTs, glucose, prolactin, clotting STI screen Parental karyotyping Karyotyping POC Antiphospholipid antibodies Pelvic US to measure cervical length. Hysteroscopy/laparoscopy Luteal phase endometrial biopsy (2 in consecutive cycles)
Definition of premature ovarian failure
Ovarian failure or insufficiency occurring <40 years old
Causes of premature ovarian failure
Bilateral oophorectomy
Ovary RT
Chemo
FH
Hormone levels in premature ovarian failure
High FSH
Low oestrogen
Management of premature ovarian failure
DEXA scan - consider adcal-D3 and bisphosphonates
HRT
Advise that still need to use contraception as spontaneous pregnancy occurs in 5-10%
How to test for antiphospholipid syndrome
Anti cardiolipin antibodies
Lupus anticoagulation antibodies
Partial prothromboplastin time
Symptoms of ovarian hyper stimulation
Tense ascites Pleural effusion Hypercoagulation N+V Oliguria
