Infertility Flashcards
What is the definition of infertility?
How many couples suffer from this
Failure to achieve a pregnancy after 12 months or mor of regular unprotected sexual intercourse.
1/5 couples deal with this
Primary vs secondary infertility
- Primary: not previously been pregnant and struggling now
- Secondary: Struggling now but have had one or more previous pregnancies
What are the proportional causes of the infertility issues
Female Factors: 60%
- Disorders of the fallopian tubes and/or endometriosis
- Disorders of ovulation
Male Factors: 25%
- seminal abonormalities
Both male and female: 15%
Unexplained: 20-30%
Female factors that make up for infertility account for ~60% of the aetiology. Of this disorders of the fallopian tube and ovulation are common. What specific types of issues can occur?
Ovulation Failure:
- PCOS (85%)
- hypothalamic amenorrhoea
- ovarian failure
Tubal Disease:
- PID
- Peritonitis
- Pelvic adhesions following bowel/pelvic surgery
Endometriosis:
After one episode of PID ___% of women are female and after three episodes ____%
After one episode of PID 10% of women are female and after three episodes 50%
anatomical and sperm reasons for an infertile male?
Anatomical:
- Congenital/acquired disease of hypothalamus or pituitary
- Cryptorchidism (undescended testes)
- Genetic abnormalities (Klinefelters)
- Surgery/trauma
Sperm:
- Abnormal spermatogenesis (2° to mumps, orchitis, chromosomal abnormalities, chemical/radiation exposure)
- oligospermia/azoospermia
- abnormal morphology or motility
What is Fecundity? How is it measured
Capacity to concieve. Measured in a monthly probability of conception.
Average monthly chance of conceiving in normal fertile couples is ____
Average duration for fertile couple to conceive is ___
Average monthly chance of conceiving in normal fertile couples is 20%
Average duration for fertile couple to conceive is 3 months
What on examination of a women could indicate potential infertility?
General:
- Increased BMI
- Fat distribution central adiposity an indication of insulin resistance
- Short stature, webbed neck Turner’s
- Incomplete secondary sexual characteristics; hypogonadism
- Hirutism . PCOS
Abdominal Exam:
- scars, masses, tenderness
PV Exam:
- Tenderness in adexae . PID
- Palpable tender nodules . Endometriosis
- Vaginal/cervical abnormalities . Mullerian Abnormality
What on examination of a man could indicate infertility?
- General observations. Vital signs, BMI. Presence of secondary sexual characteristics (hair distribution, muscle mass, adiposity)
- Gynaecomastia
- Abdomen or inguinal: scars from previous surgery
- External genital examination
- Scars, penis (position of meatus),
- Scrotum:
- testicular size (Prader orchidometer), consistency, presence of masses, location
- epididymis: induration, engorgement, cyst
- spermatic cord: presence of varicocele
What investigations do you want to do on a female with suspected infertility?
- Full antenatal blood screen
- Rubella, syphilis, HIV
- Assess immunity to varicella if not positive history
- Hepatitis B antigen (HBsAg), hepatitis C antibodies, HIV status
- STI swab for chlamydia and gonorrhoea
- HbA1c
- Cervical smear
- AMH level
- Day 2-4 of cycle: FSH level and oestrodiol levels
- Hormones
- Progesterone (mid luteal rise > 30mmol/L in 3 cycles, 6-8 days before period – Ovulation >20nmol/l) If variable more then one measurement may be needed
- Testosterone
- LH (elevated days 2-5)
- FSH • LH:FSH ratio (elevated in PCOS)
- Thyroid (hypothyroidism)
- Prolactin (produced by pituitary, increased levels interferes with ovarian function)
- USS • View follicle development or change to secretory endometrium.
- Laparoscopy/hysterosalpingogram • Assess tubal patency
What does the AMH level measure?
Ovarian reserve
What investigations could you do on a male with suspected infertiility?
- Semen Analysis: if abnormal repeat 4-6 weeks later
- Severe oligospermia/azoospermia
- Hep B antigen (HBsAg), hepatitis C antibodies, HIV status
- Scrotal ultrasonography
How/when should you collect a semen sample?
Best collected via masturbation following 3 days of abstinenece and taken to labtests within 1hour of collection
What are the indications for Scrotal USS
Indicated in patients with infertility + risk factors for testicular cancer
Also do a transrectal USS if obstructive azoospermia is suspected.