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Case 23 - Infertility > Infertility > Flashcards

Infertility Flashcards

1
Q

Definition of infertility

A

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

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2
Q

Factors affecting fertility

A

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

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3
Q

HPG axis and requirements for fertility

A

1 - LH, FSH, Prolactin, TFTs
2 - Ovulation, sperm production
3 - Tubal potency, uterine anatomy

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4
Q

Anovulation causes (ovaries do not release oocyte during ovulation cycle)

A 
Polycystic ovary syndrome
Hypogonadotrophic hypogonadism
Premature ovarian insufficiency
Hyperprolactinaemia
Hypo/hyperthryoidism
Pregnancy
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5
Q

Polycystic ovary syndrome causes and criteria for diagnosing

A

Multifactorial - neural, metabolic, environmental, genetic

Rotterdam criteria:

  1. Oligo/amenorrhoea (menstruation)
  2. Hyperandrogenism/hyperandrogenaemia
  3. Polycystic ovaries on USS
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6
Q

Other things that can mimic PCOS

A

Congenital adrenal hyperplasia
Cushing’s
Androgen secreting tumour
Steroid abuse

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7
Q

PCOS signs/symptoms

A

Oligo/amenorrhoea
Hirsutism, acne, male patetrn balding
Obesity and metabolic syndrome

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8
Q

LT risks associated with PCOS

A

DMT2
Gestational diabetes
CVS and HTN
Endometrial hyperplasia and carcinoma

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9
Q

PCOS investigations

A

Elevated LH/FSH
Pelvic USS
Eleavted free T and FAI

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10
Q

Hypogonadotrophic hypogonadism/hypothalamic amenorrhoea

A

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)

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11
Q

Hypergonadotrophic hypogonadism/premature ovarian insufficiency

A

High FSH, high LH and low estradiol
Problem is ovary - menopausal symptoms

causes - idiopathc, automimmune, turner’s

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12
Q

Hyperprolactinaemia

A

High PRL
Micro PRL diagnostic, eleavted macro PRL not diagnostic

Oligomenorrhoea, headache, bitemporal hemianopia, galactorrhoea (milky nipple discharge)

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13
Q

Thyroid dysfunction

A

Anovulation
heavy menstrual bleeding
Miscarriage
Stillbirth

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14
Q

Tubal damage causes

A

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

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15
Q

Uterine factors

A

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

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16
Q

causes of male infertility

A 
Test dysfunction
Obstructive
Varicocele
Endocrine
Autoimmune
Drugs
Environmental
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17
Q

testicular dysfunction

A

Most common
failure of spermatogenesis - trauma (tortion), crytorchidism, infection (recent UTI, mumps), neoplasm, chemo, Klinefelter’s

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18
Q

Obstructive causes of male infertility

A

Azoospermia
Congenital - absence of vas
iatrogenic - vasectomy
Cystic fibrosis - bilateral vas absence

19
Q

varicocele causes of male infertility

A

Abnormally tortuous veins in spermatic cord

May be present in fertile men, surgery if symptomatic but does not improve sperm count/qaulity

20
Q

endocrine causes of male infertility

A

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

21
Q

Autoimmune causes of male infertility

A

Anti-sperm antibodies

22
Q

Drug causes of male infertility

A

Recreational - tobacco, alcohol, marijuana
Anabolic and CCSs - may not be reversible
SSZ
Anti-fungals
Erectile dysfunction - BB, anti-depressants
Chemo

23
Q

Environmental causes of male infertility

A

heat, radiation

24
Q

Unexplained causes of infertility

A

Idiopathic
All investigations normal
maternal age main contributory factor

25
Q

Investigations in infertility assessment for females

A 
Reproductive hormones
Ovulation
Ovarian reserve/response to gonadotrophin stimulation
Transvaginal USS
Hysterosaphingography (HSG)
Laparoscopy and dye test
Rubella immunity
Chlamydia trachomatis
26
Q

Reproductive hormones for female infertility assessment

A

LH, FSH, PRL, TFTs, E2, T
Day 1-5 (early follicular phase)

Additional tests if abnormalities seen

27
Q

Ovulation investigations for female infertility assessment

A

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

28
Q

Ovarian reserve/response to gonatrophin stimulation investigations for female infertility assessment

A

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

29
Q

Transvaginal USS for female infertility assessment

A

Ovary - antral follicle count, polycystic appearance of ovaries, ovarian cysts
Uterus - endometrium, poylyps, fibroids, absent
Tubes - hydrosalphinx

30
Q

Hysterosalphingography (HSG) for female infertility assessment

A

Radio-opaque dye, X-ray,early follicular phase, abstinence, urinary hCG

31
Q

Laparoscopy and dye test for female infertility assessment

A 
Division of adhesions
Diathermy of endometriosis
Ovarian cystecomy
Salphingectomy
Tubal patency
32
Q

Rubella immunity for female infertility assessment

A 
Congenital infection
Sensorineural deafness
cardiac
Opthalmic (cataracts, glaucoma)
Microcephaly
IUGR
33
Q

Chlamydia trachomatis investigations for infertility assessment of female

A

PID, tubal damage

fetal conjuctivitis and pneumonia

34
Q

Infertility assessment for men

A

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

35
Q

general management of infertility

A 
BMI normalisation
Folic Acid 3 months pre-conception to 12 weeks
Smoking cessation
Cut alcohol intake
Regular unprotected intercourse
36
Q

Management of PCOS

A

BMI <35
Clomiphene anti-oestrogen, raises FSH, induces folliculogenesis
Gonadotropin therapy - daily FSH till pre-ovulatory follicle, USS monitoring
laparoscopic ovarian drilling
IVF

37
Q

Management of hypothalmic amenorrhoea

A

Increase weight
Decrease exercise
Daily FSH and hCG for ovulation
GnRH pulsatile administration

38
Q

Hypogonadotrophic hypogonadism

A 
No follicles
Ovulation induction not possible
WIll not respond to gonadotrophins
Egg donation
Adoption
39
Q

Hyperprolactinaemia management

A

Dopamine agonists - bromocriptine

Transphenoidal pituitary surgery

40
Q

Tubal factor management

A

Surgery for some
Specialist centres
Risk of ectopic pregnancy
IVF

41
Q

Uterine factors management

A

case-by-case basis
Hysteroscopic resection for submucosal fibroid and uterine polyp
Intramural fibroids - myomectomy
Adhesions - copper coil, hysteroscopic division

42
Q

Male factor management

A 
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
43
Q

Management of unexplained infertility

A

Regular unprotected intercourse
No ovulation induction as ovulates
No gonadotrophins as normal HPG axis
IVF after 2 yrs unprotected regular intercourse

44
Q

IVF

A

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

Case 23 - Infertility (3 decks)

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