Infertility Flashcards
What is infertility
An inability to conceive after 12 months of regular intercourse (2-3 days)
Primary = if never conceived before
When should you investigate
After 1 year of trying
Earlier if known issue
What are known issues / reasons for early referral
Age >35 Amenorrhoea / PCOS Previous pelvic surgery or on genitalia Previous STI - inc HIV / hep B Abnormal genital exam Varicocele Systemic illness
When are you most fertile
Day 10-17 of cycle
What happens during your cycle
Luteal phase after ovulation = 14 days constant
Follicular = average 14
Ovulate on last day of follicle
When do you measure progesterone levels to see if ovulated
When do you ovulate
7 days prior to next period - usually day 21
14 days prior to next period
What can cause infertility
Ovulatory Tubal factor Uterine / endometrial abnormality Sexual problem Azoospermia Unexplained
What causes ovulatory disorder
Any cause 2 amenorrhoea Exercise / weight loss Hypogonadotrophic hypogonadism - hypothalamus / pituitary PCOS Ovarian failure
Wha causes tubal issue s
PID Previous ectopic Previous surgery Sterile Endometriosis Fibroid compressing
What is unexplained
Test to see if eggs
Test to see if sperm
Can they meet and implant
If all fine= unexplained
What do you look in examination of the male
BMI Features of increased androgen - Increased fat - Decreased hair Abdo and inguinal exam STI Testicular size Varicoccele Vas deferens
What do you look for in female examination
BMI Fat and hair distribution Hirsutism Galactorrhoea Abdo and pelvic exam Acanthosis nigrican
What does hirsutism suggest
PCOS = most common
Androgen excess
Adrenal hyperplasia
Cushings
What does aconthosis nigrican suggest
Androgen excess
Insulin resistance
When does fertility decrease
Age
Chemo / RT
Can preserve embryos by freezing
What are 1st line investigations do you do in male and female
Computerised semen analysis
Mid literal progesterone or FSH / LH / testosterone if irregular to see if ovulating
What other female investigations are done prior to clinic
BMI - if low anovulation? if high PCOS? Pelvic and breast exam C+G Rubella TFT / prolactin Pelvic USS to look for structural
What do you do at clinic
Tubal potency test for blockage
HSG or HyCOSy - hysterosalpingography
Laparoscopy - Dx and can treat
How do you treat infertility / general advice
Rx underlying condition e.g. PID Regular intercourse 2-3 days Smoking and drinking advice Aim BIM Folic acid 400mg
What do you do for ovulatory disorder
Clomifene = 1st line
Gonadotrophin
Metformin
FSH Injection
What is Clomifene
SERM
Triggers FSH and LH release regularly
Scan to see 1 dominant follicle
What are risks of clomifene
Multiple pregnancy
Ovarian cancer
Hyperstimulation
Can only use for 6 cycles
When do you use gonadotrophin
No ovulation after 6 cycles
What is metformin helpful in
Underlying insulin resistance
May be used in addition to clomifene as increases effectiveness if resistant
What do you do for tubal factor
Surgery to remove or bypass tube
- Risk of ectopic
IVF
What is the only option for unexplained
IVF
NO ovarian stimulation
What is criteria for IVF
<42
BMI <30
Non smoker
No children
What are the symptoms of ovarian hyper stimulation and how do you treat
- More common with gonadotrophin / hCG Rx over clomifene
Abdo pain Bloating N+V Diarrhoea Hypotension
If severe Ascites Oliguria Raised haematocrit VTE / ARDS = critical
Due to cystic enlargement so more at risk if have PCOS
Fluid resus + VTE prophylaxis
What is azoospermia
No sperm in ejaculate
What are testicular causes of azoospermia
Hypogonadotrophic hypogonadism
Klienfelter syndrome
What does Klienflter present with
XXY Hypogonadism Low testosterone Small testicles Azoospermia
What are post-testicular causes
Radiation Congenital Infective - mumps. STI Absence of vas deferends Vasectomy
What puts you at risk of azoospermia
Smoking
Exposure to heat and chemical
Anabolic steroid
What investigations should be done
FSH / LH Testosterone Prolactin Karyotype CF screem Serum analysis
How do you treat Klienfelter
Testosterone injection
How do you treat azoospermia
Surgical sperm retrieval Intra-uterine insemination Reverse vasectomy Donor insemination IVF
What is PCOS
Syndrome of ovarian dysfunction
Features of hyperandrogegism and PCO
Causes 80% of fertility issues
What causes PCOS
Disorder LH production
Insulin resistance so increased levels
Increased androgen disrupts folliculogenesis
RF
- Obesity
- FH
- Ethnicity
What criteria used to Dx
Rotterdam
Require 2/3
What is Rotterdam criteria
PCO
Anovulation or oligo
Androgenic symptoms or elevated total or free serum testosterone (low SHBG)
What are symptoms of increased androgen
Hirsutism Acne Deep voice Enlarged clit Cushionoid Excess testosterone
Being on the COCP can hide these symptoms
What are other symptoms
Obesity Infertility Irregular cycle Can have heavy periods Plenty oestrogen but also high androgen Insulin resistance = DM (insulin promotes release of more androgens) CVS disease Aconthosis nigrican Chronic pelvic pain Depression
How do you Dx / investigate at GP
Basic obs, BM, urine dip
Bloods - FBC, U+E, LFT, TFT, total testeroterone or sex hormone binding
Further Mid literal progesterone Hormonal profile Pelvic / transvaginal USS Check for impaired glucose tolerance Full infertility work up if want to conceive
When do you start on induction therapy
If all hormones are fine
What is hormonal profile
LH - raised LH / FSH ratio = raised FSH TSH Prolactin Testosterone = can be raised Oestrogen
What are general measures
Weight loss = 1st step in increasing fertility
Exercise
Stop smoking
Monitor BP / lipid
Screen for DM every 3-5 years
Endometrial cancer risk - mineral coil or COCP to get regular bleed
What is step wise approach for fertility
Clomifene = 1st line Metfomrin = increase insulin resistance Gonaotropin - FSH or LH injection when follicle grown IVF = last resort
What does clomifene do
Binds to oestrogen receptor in pituitary
Trigger release of FSH and LH
What helps with androgen symptoms as anti-androgen / Hirstusim
Combined OCP Facial hair cream Metformin Cyproterone acetate / spironolactone = anti-androgen but must be on contraception Co-cyprindol - regulate menstruation
What do you give for endometrial protection as
anovulation increases risk / regulate menstruation
COCP
- Want 3-4 bleeds
Progestogen
Mirena IUS
What are surgical options
Drilling
What are complications of PCOS
DM type 2 Obesity Higher CVD risk Higher VTE risk Endometrial hyperplasia OSA Infertility Miscarriage
What is PCO
> 10 cyst
Not technically cyst - follicles that start to develop then arrest
Hypo-echoic
or volume >12
What must you exclude
Other causes of hyperandrogegism Adrenal or ovarian tumour Adrenal hyperplasia Cushing Pituitary tumour
What is metformin useful for
Increasing effectiveness of clomifene
Reduce gestational DM and miscarriage
Reduce Hirsutism
What is risk of anovulation in PCOS
No CL so no progesterone
No uterine bled and shed of lining
Increased risk of endometrial hyperplasia
Get irregular breakthrough bleed
What must you exclude if rapid onset hirsutism and very high testoerstoerne
testosterone secreting tumour
If abnormal prolactin
MRI head for prolactinoma
