Infertility Flashcards
Definition of infertility
Inability to conceive after 1-2 years, regular and unprotected sex in absence of reproductive physiology
Investigate after 1 year unless women aged over 36, known cause of infertility, predisposing risk factors
Factors affecting fertility
Age (loss of no of oocytes, loss of oocyte quality)
Smoking
Alcohol
Obesity (BMI over 30 causes reduced fertility)
Low birth weight
Tight underwear
NSAIDs
HPG axis and requirements for fertility
1 - LH, FSH, Prolactin, TFTs
2 - Ovulation, sperm production
3 - Tubal potency, uterine anatomy
Anovulation causes (ovaries do not release oocyte during ovulation cycle)
Polycystic ovary syndrome Hypogonadotrophic hypogonadism Premature ovarian insufficiency Hyperprolactinaemia Hypo/hyperthryoidism Pregnancy
Polycystic ovary syndrome causes and criteria for diagnosing
Multifactorial - neural, metabolic, environmental, genetic
Rotterdam criteria:
- Oligo/amenorrhoea (menstruation)
- Hyperandrogenism/hyperandrogenaemia
- Polycystic ovaries on USS
Other things that can mimic PCOS
Congenital adrenal hyperplasia
Cushing’s
Androgen secreting tumour
Steroid abuse
PCOS signs/symptoms
Oligo/amenorrhoea
Hirsutism, acne, male patetrn balding
Obesity and metabolic syndrome
LT risks associated with PCOS
DMT2
Gestational diabetes
CVS and HTN
Endometrial hyperplasia and carcinoma
PCOS investigations
Elevated LH/FSH
Pelvic USS
Eleavted free T and FAI
Hypogonadotrophic hypogonadism/hypothalamic amenorrhoea
Low FSH and low estradiol
Hot flushes, vaginal dryness, mood changes (menopausal symptoms)
Causes - response to stress, pituitary surgery or irradiation, inflamm (sarcoidosis, TB),, congenital (kalimann’s syndrome), sheehans (postpartum pituitary necrosis)
Hypergonadotrophic hypogonadism/premature ovarian insufficiency
High FSH, high LH and low estradiol
Problem is ovary - menopausal symptoms
causes - idiopathc, automimmune, turner’s
Hyperprolactinaemia
High PRL
Micro PRL diagnostic, eleavted macro PRL not diagnostic
Oligomenorrhoea, headache, bitemporal hemianopia, galactorrhoea (milky nipple discharge)
Thyroid dysfunction
Anovulation
heavy menstrual bleeding
Miscarriage
Stillbirth
Tubal damage causes
Infection - PID, chlamydia, pelvic infection (appendicitis, septic miscarriage, TB), pelvic inflamm (Crohn’s), iatrogenic (adhesions post surgery), risk of ectopic pregnancy
Endometriosis - adhesions
Hydrosalphinx - fluid toxic to gametes/embryo
Uterine factors
Fibroids - subserosal, at tubal ostia - occlude passage, to uerine cavity - miscarriage, IUGR, PTL
Intrauterine adhesions - endometritis, trauma - excessive cutterage, ashermans’s
Congenital anomalies - same as general population, risk of miscarriage, associated renal onomalies, if found renal USS
causes of male infertility
Test dysfunction Obstructive Varicocele Endocrine Autoimmune Drugs Environmental
testicular dysfunction
Most common
failure of spermatogenesis - trauma (tortion), crytorchidism, infection (recent UTI, mumps), neoplasm, chemo, Klinefelter’s
Obstructive causes of male infertility
Azoospermia
Congenital - absence of vas
iatrogenic - vasectomy
Cystic fibrosis - bilateral vas absence
varicocele causes of male infertility
Abnormally tortuous veins in spermatic cord
May be present in fertile men, surgery if symptomatic but does not improve sperm count/qaulity
endocrine causes of male infertility
Hypogonadotrophic hypogonadism
kallmann - absent GnRH neurons, low LH and T, insomnia, failed pubertal, fertility - GnRH pump or LH/FSH infections
Puberty/libido - testosterone
Hyperprolactinaemia - impotence, normal semen analysis
Autoimmune causes of male infertility
Anti-sperm antibodies
Drug causes of male infertility
Recreational - tobacco, alcohol, marijuana
Anabolic and CCSs - may not be reversible
SSZ
Anti-fungals
Erectile dysfunction - BB, anti-depressants
Chemo
Environmental causes of male infertility
heat, radiation
Unexplained causes of infertility
Idiopathic
All investigations normal
maternal age main contributory factor
Investigations in infertility assessment for females
Reproductive hormones Ovulation Ovarian reserve/response to gonadotrophin stimulation Transvaginal USS Hysterosaphingography (HSG) Laparoscopy and dye test Rubella immunity Chlamydia trachomatis
Reproductive hormones for female infertility assessment
LH, FSH, PRL, TFTs, E2, T
Day 1-5 (early follicular phase)
Additional tests if abnormalities seen
Ovulation investigations for female infertility assessment
Menstrual regularity
Mid-luteal progesterone - 7 days prior to next expected period progesterone >30nmol is ovulatory, in irregular cycle weekly urinary E2 and P4 4-6 weeks
Ovarian reserve/response to gonatrophin stimulation investigations for female infertility assessment
FSH >9 - poor response
Anti-mullerian hormone - primordial follicles, high level >25 is god reserve, low level <5.4 is poor reserve
Antral follicle count on USS - >16 is good response, <4 is poor response
Transvaginal USS for female infertility assessment
Ovary - antral follicle count, polycystic appearance of ovaries, ovarian cysts
Uterus - endometrium, poylyps, fibroids, absent
Tubes - hydrosalphinx
Hysterosalphingography (HSG) for female infertility assessment
Radio-opaque dye, X-ray,early follicular phase, abstinence, urinary hCG
Laparoscopy and dye test for female infertility assessment
Division of adhesions Diathermy of endometriosis Ovarian cystecomy Salphingectomy Tubal patency
Rubella immunity for female infertility assessment
Congenital infection Sensorineural deafness cardiac Opthalmic (cataracts, glaucoma) Microcephaly IUGR
Chlamydia trachomatis investigations for infertility assessment of female
PID, tubal damage
fetal conjuctivitis and pneumonia
Infertility assessment for men
Semen analysis
- bio variation in quality, abstinence 3 days, avoid binge drinking, UTI/recent illness can affect sample
Normal FSH and T - obstructive
Low FSH and T - hypo hypogonadism (Kallmann’s)
Low FSH and high T - anabolics
High FSH and normal T - failure of spermatogenesis
High FSH and low T - complete testicular failure
general management of infertility
BMI normalisation Folic Acid 3 months pre-conception to 12 weeks Smoking cessation Cut alcohol intake Regular unprotected intercourse
Management of PCOS
BMI <35
Clomiphene anti-oestrogen, raises FSH, induces folliculogenesis
Gonadotropin therapy - daily FSH till pre-ovulatory follicle, USS monitoring
laparoscopic ovarian drilling
IVF
Management of hypothalmic amenorrhoea
Increase weight
Decrease exercise
Daily FSH and hCG for ovulation
GnRH pulsatile administration
Hypogonadotrophic hypogonadism
No follicles Ovulation induction not possible WIll not respond to gonadotrophins Egg donation Adoption
Hyperprolactinaemia management
Dopamine agonists - bromocriptine
Transphenoidal pituitary surgery
Tubal factor management
Surgery for some
Specialist centres
Risk of ectopic pregnancy
IVF
Uterine factors management
case-by-case basis
Hysteroscopic resection for submucosal fibroid and uterine polyp
Intramural fibroids - myomectomy
Adhesions - copper coil, hysteroscopic division
Male factor management
Intracytoplasmic sperm injection if oligospermia/poor morphology/motility Obstructive - surgical retrieval and insemination Hypogonadtophic hypogonadism - gonadotrophic therapy Anabolics - expectant if recovered, IVF/ICSI if partial recovery, donor sperm if no recovery Failing spermatogenesis (Klinefelters) - sperm freezing Testicular failure (chemo) - sperm freezing if time, donor sperm
Management of unexplained infertility
Regular unprotected intercourse
No ovulation induction as ovulates
No gonadotrophins as normal HPG axis
IVF after 2 yrs unprotected regular intercourse
IVF
Aim to induce as many follicles as possible
Downregulation with GnRH analogues
Daily FSH
Frequent USS monitoring
Egg collection 36-38h from trigger
Semen collection
Oocytes and sperm incubated overnight or intracytoplasmic sperm injection
Embryo transfer day 3 or day 5 blastocyst
One embryo transfer
Risks - failed cycle, bowel/vessel injury, infection, miscarriage, ectopic, multiple pregnancy
