Infertility Flashcards
what is infertility?
inability of a couple to conceive after 12 months of regular intercourse without use of contraception
during the infertility consultation it is necessary to ascertain what?
if eggs are available
if sperm are available
can they meet
can the embryo implant
aspects of a female infertility Hx
o Duration of infertility o Previous contraception o Fertility in previous relationships o Previous pregnancies and complications o Menstrual history o Medical and surgical history o Sexual history o Previous investigations o Psychological assessment
aspects of female infertility exam
o Weight o Height o BMI (kg/m2) o Fat and hair distribution o Galactorrhoea o Abdominal examination o Pelvic examination
name a scoring system for female hirsutism
Ferriman Gallwey Score
biochemical measurements in female infertility
- Testosterone
- Dehydroepiandrosterone sulphate (DHEAS)
a. If > 700mcg/dL (18.9 micromol/L) adrenal CT is recommended to look for an androgen
secreting adrenal tumour - 17-OH progesteron
what is acanthosis nigricans and what is it a sign of?
Acanthosis nigricans is a skin condition characterized by areas of dark, velvety discoloration in body folds and creases. The affected skin can become thickened. Most often, acanthosis nigricans affects your armpits, groin and neck. It is a sign of androgen excess.
what do you assess for on female infertility pelvic exam?
- Masses
- Pelvic distortion
- Tenderness
- Vaginal septum
- Cervical abnormalities
female infertility baseline investigations
- Rubella immunity
- Chlamydia
- TSH
- If periods are regular: mid luteal progesterone (7 days prior to expected period)
- If periods are irregular: day 1-5 FSH, LH, PRL, TSH, testosterone
male infertility baseline investigations
semen analysis
investigations at fertility clinic
- Pelvic USS
- Physical examination
- Testing for ovulation
- Semen analysis repeat if required
- Tubal patency test
discuss ovulation assessment
Women who are concerned about their fertility should be asked about the frequency and regularity
of their menstrual cycles. Women with regular monthly cycles should be informed that they are likely
to be ovulating. Women who are undergoing investigations for infertility should be offered a blood
Figure 2 Acanthosis Nigricans
test to measure serum progesterone in the mid luteal phase of their cycle (day 21 of a 28-day cycle)
to confirm ovulation even if they have regular cycles. Women with prolonged irregular menstrual
cycles should be offered a blood test to measure serum progesterone. Depending upon the timing of
menstrual periods, this test may need to be conducted later in the cycle (for example day 28 of a 35-
day cycle) and repeated weekly thereafter until the next menstrual cycle starts. Women with irregular
menstrual cycles should be offered a blood test to measure serum gonadotrophins (FSH and LH).
discuss the investigation of suspected tubal and uterine abnormality
Women who are not known to have comorbidities (such as pelvic inflammatory disease, previous
ectopic pregnancy or endometriosis) should be offered hysterosalpingography (HSG) to screen for
tubal occlusion. As this is a reliable test for ruling out tubal occlusion, and it is less invasive and makes
more efficient use of resources than laparoscopy.
male infertility Hx
• Developmental o Testicular descent o Change in shaving frequency o Loss of body hair • Infections o Mumps o STDs • Surgical o Varicocele repair o Vasectomy • Previous fertility • Drugs/environmental o Alcohol o Smoking o Anabolic steroids o Chemotherapy o Radiation o Recreational drugs • Sexual history o Libido o Frequency of intercourse o Previous fertility assessment • Chronic medical illness
male infertility exam
• Weight • Height • BMI • Fat and hair distribution • Abdominal and inguinal examination • Genitals o Epididymis o Testes o Vas deferens o Varicocele
what STDs can cause epididymitis?
chlamydia
gonorrhoea
what is a varicocele? discuss its implications in infertility
A varicocele is a dilation of the pampiniform plexus of the spermatic veins in the scrotum. Most men
with varicocele and presumptive infertility have abnormal semen parameters, including low sperm
concentration and abnormal sperm. Men should not be offered surgery for varicoceles as a form of
fertility treatment as it does not improve pregnancy rates.
discuss testicular size and infertility
Klinefelter syndrome is one of the most common causes of primary hypogonadism with impaired
spermatogenesis and testosterone deficiency. Up to 1 in 500-700 phenotypic males are affected by
Klinefelter’s. Approximately 10-15% of infertile men with azoospermia can be accounted for with this.
It is characterised by sex chromosome aneuploidy – XXY. These patients have very small testes and
almost always azoospermia.
what condition can cause congenital bilateral absence of the vas?
CF
when to refer couples about infertility?
• 1 year of trying • Unless o Period irregularity o PMHx o Testicular problems • Abnormal tests • HIV/Hep B • Anxiety • Age o <35 – 1 year o 35-45 – 6 months o >45 – little can be offered
discuss group 1 ovulatory disorder: hypothalamic amenorrhoea or hypogonadotropic hypogonadism
In women with group I anovulatory infertility they can improve their chance of regular ovulation,
conception and an uncomplicated pregnancy by increasing their BMI if it is less than 19 and/or
moderating their exercise levels if it is high. Offer women pulsatile administration of GnRH or
gonadotrophins with LH activity to induce ovulation
discuss group 2 ovulatory disorder: Hypothalamic-Pituitary-Ovarian Dysfunction (Predominately PCOS)
PCOS is characterised by:
- Androgen excess
a. Hirsutism
b. Testosterone - Infrequent periods
a. Anovulation - Polycystic ovaries
a. USS
discuss group 3 ovulatory disorder: ovarian failure
With all ovulatory disorders: 1. Treat underlying cause 2. Weight loss/gain a. BMI > 18 and <35 3. Ovulation induction a. Clomifene i. Selective oestrogen receptor modulator ii. Dose – 50-150mg day 2-6 iii. Monitoring 1. Follicle scanning in 1st cycle 2. 15% require dose adjustment iv. Side effects 1. Vasomotor 2. Visual b. Gonadotrophins i. No ovulation with clomifene ii. Ovulation but no pregnancy iii. FSH (by injection) iv. Up to 3-6 cycles
investigations for azoospermia
hx
exam
fsh, lh, testosterone, karyotype, PRL
CF screen
discuss unexplained infertility
Do not offer oral ovarian stimulation agents (e.g. clomifene) to women with unexplained infertility.
Inform women that clomifene citrate as a stand-alone treatment does not increase the chances of a
live birth pregnancy. Advise women who are having regular unprotected sexual intercourse to try and
conceive for a total of 2 years (This can include up 1 year before their fertility investigations) before
IVF will be considered. Offer IVF.
