Infertility Flashcards
Define infertility
Inability of a couple to conceive after 12 months of regular intercourse without use of contraception
How common is infertility?
1 in 7 couples report infertility problems
80% of couples in the general population will conceive within 1 year if…
The woman is <40y and they do not use contraception & have regular sexual intercourse
Of those who do not conceive in the first year, about a half will do so in the second year
After how long of trying with regular intercourse, not using protection do we investigate if the couple are struggling to conceive?
1 year
What are the main questions you should ask yourself if a couple are struggling to conceive?
Are eggs available?
Are sperm available?
Can they meet?
Can embryo implant?
What questions should you ask in the female infertility hx?
Duration of infertility Prev contraception Fertility in prev relationships Prev pregnancies and complications Menstrual hx Medical & surgical hx Sexual hx Prev investigations Psychological assessment
What should you examine a female for presenting with infertility?
Weight, height, BMI Fat and hair distribution (hirsutism may indicate PCOS, cushings, acromegaly) Galactorrhoea Abdominal examination Pelvic examination
What score can you use to assess androgen xs?
Ferriman Gallwey score
What biochemical tests can you do to measure suspected androgen xs?
Testosterone
DHEAS - if >700mcg/dL do CT of adrenals to check for androgen-secreting tumour
17-OH progesterone
Apart from hirsutism what is another sign of androgen xs?
Acanthosis nigricans
What are you feeling for in pelvic examination?
Masses Pelvic distortion Tenderness Vaginal septum Cervical abnormalities
What is the classic triad of fibroid symptoms?
Pressure symptoms
Period problems
Infertility
What are your baseline investigations for infertility?
Female -
Rubella immunity, chlamydia, TSH, if periods regular - midluteal progesterone (7 days prior to expected period)
If periods irreg do day 1-5 FSH, LH, PRL, TSH, testosterone
Male partner semen analysis
Why do you measure midluteal progesterone?
If they have ovulated their progesterone should be high as they would have made a corpus luteum
Why would you want to measure TSH in an infertile woman?
In hypothyroidism TSH release is increased so there is increased prolactin production and this inhibits GnRH, leading to lower oestrogen levels & no ovulation
What investigations can you do on an infertile lady?
Pelvic USS
Physical Rx
Testing for ovulation
Tubal patency test
How do you assess ovulation?
Ask about frequency & regularity of menstrual cycles
Those with regular monthly menstrual cycles are likely to be ovulating
Women should be offered a blood test to measure serum progesterone in the mid-luteal phase of their cycle (day 21-28) to confirm ovulation even if they have regular cycles
Woman with irregular cycles should be offered the same as above (may need to adjust timing & repeat weekly until the menstrual cycle starts) & should be offered LH and FSH measurement
Who should be offered test for tubal patency & uterine abnormalities?
Women who are not known to have cormorbs (e.g. PID, prev. ectopic, endometriosis) should be offered hysterosalphingography to screen for tubal occlusions
Can do HyCoSy (HSG with contrast) or laparoscopy
What should you ask in male hx of infertility?
Developmental - testicular descent, change in shaving frequency, loss of body hair
Infections - mumps, STIs
Surgical - variocele repair, vasectomy
Prev. fertility
Drugs, alcohol, smoking, anabolic steroids, chemo, radiation
Sexual hx - libido, freq. of intercourse
Any chronic illness
What is involved in male examination of infertility?
Wt, height, BMI
Fat and hair distribution (hypoandrogenism)
Abdominal & inguinal examination
Genital examination - epididymis, testes, vas deferens, varicocele
What may cause epididymitis?
STDs - chlamydia trachomatis, gonorrhoea
(causes ST necrosis & disrupts spermatogenesis)
TB and mumps can also cause
What is a varicocele?
Dilatation of pampiniform plexus of spermatic veins in scrotum
Does varicocele affect fertility?
Most men with presumptive infertility & varicocele have abnormal semen parameters, incl. low sperm concentration
Should you do surgery on varioceles to treat infertility?
NO - doesn’t improve pregnancy rates
What is Klinefelter syndrome?
One of the most common causes of primary hypogonadism with impaired spermatogenesis & testosterone deficiency
(10-15% men with azoospermia)
XXY (sex chromosome aneuploidy)
Patients have v. small testes and almost always have azoospermia
What is considered small testicular size?
Vol. below 15ml
How can you measure testicular size?
Orchidometer
What are issues with the vas deferens that can lead to infertility?
Cystic fibrosis mutations are associated with congenital bilateral absence of the vas deferens
How do men give a sperm sample?
Abstain from sex/masturbation for at least 3 days (no longer than 7)
Collect whole ejaculate
Bring to lab at body temp
When should you refer to the infertility clinic?
After 1y of trying unless Period irreg, PMH, testicular probs Abnormal tests HIV/HepB Anxiety Age 35-45y (after 6m), >45 little can be offered
What is the most common cause of infertility?
Tubal damage
What is the WHO classification of ovulation disorders?
Group 1 - hypothalamic pituitary failure (hypothalamic amenorrhoea/hypogonadotrophic hypogonadism)
Group 2 - hypothalamic-pituitary-ovarian dysfunction (mostly PCOS)
Group 3 - ovarian failure (POI)
What is Rx for group 1 anovulatory failure?
Can improve changes of pregnancy by increasing their body wt if BMI <19 and moderating their levels of exercise (if they do too much)
Can offer pulsatile administration of gonadoptrophin-releasing hormone or gonadrotrophins with lutenising hormone activity to induce ovulation
What sorts of things fit into group 1 ovulation disorders?
Low body weight, stress or exercise related amenorrhoea
Craniopharyngiomas etc. affecting the hypothalamus
Amenorrhoea assoc. w. anosmia (e.g. Kallmann’s syndrome)
Idioapthic
What is the Rx for infertility in those with PCOS?
Weight loss/gain
BMI >18 and <35
Ovulation induction - clomifene or gonadotrophins
How does clomiphene work?
Blocks oestrogen receptors on anterior pituitary –> increased FSH
How do you monitor clomiphene?
Follicle scanning in 1st cycle
What are the SEs of clomiphene?
Vasomotor/visual
How do gonadotrophins work in Rx infertility?
Stimulate follicular development and ovulation
What is the issue with gonadotrophin therapy?
Multifollicular recruitment & risks of multiple pregnancy/ovarian hyperstimulation syndrome
Start with low doses and increase in small increments and scans are advised for every gonadotrophin OI cycle
When is it recommended to use gonadotrophins in treating infertility?
No ovulation with clomiphene or ovulation but no pregnancy
Given up to 3-6 cycles
How are the gonadotrophins given?
FSH by injection
How do you Rx tubal factors/endometriosis causing infertility?
Surgery for hydrosalphinges (via laparoscopy) before IVF Rx (as this improves chance of live birth)
What is hydrosalpinx?
When the fallopian tube becomes blocked with serous clear liquid
What Rx is there for male factors causing infertility?
IVF/ICSI
Intra-uterine insemination
Surgery - reversal of vasectomy/surgical sperm retrieval
Donor insemination
How are the causes of azoospermia split up?
Testicular –> normogonadotrophic, hypogonadism, hypergonadotrophic
Post-testicular - iatrogenic, congenital, infective
What Ix should you do for azoospermia?
Hx, Ex,
FSH, LH, testosterone, karyotype, PRL
CF screen
How is a surgical sperm retrieval done?
Micro-epidydimal sperm aspiration
Testicular sperm extraction
What agents can you offer to woman with unexplained infertility?
DO NOT offer ovulation stimulatory agents (e.g. clomiphene) - as a stand alone Rx it will not increase chances of pregnancy
What can you do for woman with unexplained infertility?
Try to conceive by having regular unprotected sex for 2 years before IVF will be considered
How does IVF work?
Eggs harvested from ovaries, fertilised in the lab, embryos undergo divisions and are re-implanted into the womb
Who gets IVF?
Those with:
Tubal problems after unsuccessful surgery
Males with IUI/DI
Ovulatory problems after unsuccessful clomiphene/gonadotrophin Rx
Unexplained after IUI/superovulation
What is ICSI?
Intracytoplasmic sperm injection
Injection of mature eggs with single sperm
Incubation over night
What is the process of freezing embryos called?
Cryopreservation
