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Reproduction > Infertility > Flashcards

Infertility Flashcards

1
Q

Incidence of infertility

A

1 in 7 couples report infertility problems

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2
Q

Infertility definitions

A

The inability of a couple to conceive after 12 months of regular intercourse without use of contraception.

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3
Q

Chance of conception

A
  • Over 80% of couples in the general population will conceive within 1 year if:
    • the woman is aged under 40 years and
    • they do not use contraception and have regular sexual intercourse.
  • Of those who do not conceive in the first year, about half will do so in the second year (cumulative pregnancy rate over 90%).
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4
Q

Female history

A
  • Duration of infertility
  • Previous contraception
  • Fertility in previous relationships
  • Previous pregnancies and complications
  • Menstrual history
  • Medical and surgical history
  • Sexual history
  • Previous investigations
  • Psychological assessment
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5
Q

Female examination

A
  • Weight
  • Height
  • BMI (kg/m2)
  • Fat and hair distribution
  • Galactorrhoea
  • Abdominal examination
  • Pelvic examination
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6
Q

Clinical measurement of androgen excess

A

Ferriman Gallwey Score

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7
Q

Biochemical measurement of androgen excess

A
  • Testosterone (T)
  • Dehydroepiandrosterone sulphate (DHEAS)
    • if DHEAS is greater than 700 mcg/dL (18.9 micromol/L) adrenal computed tomography (CT) is recommended to look for an androgen-secreting adrenal tumor
  • 17-OH Progesterone
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8
Q

What is looked for on a pelvic examination?

A
  • Masses
  • Pelvic distortion
  • Tenderness
  • Vaginal septum
  • Cervical abnormalities
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9
Q

Fibroid symptoms

A
  • Pressure symptoms
  • Period problems
  • Infertility
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10
Q

Baseline female investigations

A
  • Rubella immunity
  • Chlamydia
  • TSH
  • if periods are regular: Mid luteal progesterone ( 7 days prior to expected period)
  • if periods are irregular: Mid luteal progesterone ( 7 days prior to expected period). And repeat weekly until start if next menstrual cycle. Also measure serum gonadotrophins (FSH and LH).
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11
Q

Baseline male investigations

A

semen analysis

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12
Q

Investigations at Fertility Clinic

A
  • Pelvic Ultrasound
  • Physical examination
  • Testing for ovulation
  • Tubal patency test
  • Semen analysis repeat if required
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13
Q

Assessment of ovulation in women who are concerned about their fertility.

A
  • These women should be asked about the frequency and regularity of their menstrual cycles.
  • Women with regular monthly menstrual cycles should be informed that they are likely to be ovulating.
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14
Q

Assessment of ovulation in women who are undergoing investigations for infertility (even if they have regular menstrual cycles)

A

Mid luteal progesterone ( 7 days prior to expected period) to confirm ovulation.

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15
Q

Assessment of ovulation in women with prolonged irregular menstrual cycles.

A
  • Mid luteal progesterone ( 7 days prior to expected period). And repeat weekly until start if next menstrual cycle.
  • Also measure serum gonadotrophins (FSH and LH ).
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16
Q

Investigation of suspected tubal and uterine abnormalities

A

hysterosalpingography (HSG)

17
Q

Male history

A
  • Developmental
    • Testicular descent
    • Change in shaving frequency
    • Loss of body hair
  • Infections
    • Mumps
    • Sexually transmitted diseases
  • Surgical
    • Varicocele repair
    • Vasectomy
  • Previous fertility
  • Drugs/environmental
    • Anabolic steroids
    • Chemotherapy
    • Radiation
    • Recreational drugs
  • Sexual history
    • Libido - sexual derive
    • Frequency of intercourse
    • Previous fertility assessment
18
Q

Male examination

A
  • Weight
  • Height
  • BMI (kg/m2)
  • Fat and hair distribution (hypoandrogenism)
  • Abdominal and inguinal examination
  • Genital examination
    • Epididymis
    • Testes
    • Vas deferens
    • Varicocele
19
Q

Varicocele

A
  • is a dilatation of the pampiniform plexus of the spermatic veins in the scrotum
  • surgery for varicoceles does not improve pregnancy rates (should not be offered as a form of fertility treatment)
20
Q

Klinefelter syndrome

A

One of the most common causes of primary hypogonadism with impaired spermatogenesis and testosterone deficiency.

21
Q

Classification of ovulatory disorders

A
  • Group I: hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism).
  • Group II: hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome).
  • Group III: premature ovarian insufficiency (POI).
22
Q

WHO Group I ovulation disorders

A
  • Increasing their body weight if they have a BMI of less than 19
  • Moderating their exercise levels if they undertake high levels of exercise
  • Offer pulsatile administration of gonadotrophin-releasing hormone or gonadotrophins with luteinising hormone activity to induce ovulation
23
Q

Which criteria is used to diagnose polycystic ovary syndrome?

A

The Rotterdam criteria

24
Q

Rotterdam criteria

A

Two out of the three criteria must be met:

  • Polycystic ovaries on ultrasound or direct inspection
    • 12 or more small follicles measuring around 2-9mm or volume of ovaries >10cm2
  • Oligo or anovulation
  • usually seen in women with menstrual cycles greater than 35 days apart or with short cycles (less than 21). Even women with regular cycles may be anovulatory
  • Hyperandrogenism
    • clinical - hirstuism, acne
    • biochemical - testosterone
25
Q

Symptoms of Polycystic ovary syndrome

A

HAIR

  • Hirsutism
  • Amenorrhoa
  • Irregular periods / Increased weight
  • Reduced fertility and miscarriage
26
Q

Investigations for polycystic ovary syndrome

A
  • General blood tests
    • FBC, U&E, TFTs
  • Specific blood tests
    • Androgen levels, SHBG (sex hormone binding globulin), LH, FSH, prolactin
  • Radiology
    • Transvaginal ultrasound scan
27
Q

Treatment for polycystic ovary syndrome

A
  • Conservative
    • Weight loss
  • Medical
    • Hirsutism - oral contrceptive pills with an anti-androgen effect (eg Yasmin)
    • Subfertility - metformin may help
    • Inducing ovulation (eg clomifene)
28
Q

Complications of polycystic ovary syndrome

A
  • Infertility
  • Type 2 diabetes mellitus
  • Gestational diabetes
  • Depression
  • Increased weight
29
Q

Ovulation induction

A
  • Clomiphene
  • Gonadotrophins
  • GnRH
30
Q

Clomifene: clinical use

A
  • Selective oestrogen receptor modulator
  • Dose choice 50mg - 100mg for 5 days
  • Monitoring
    • Follicle scanning in 1st cycle
    • 15% require dose adjustment
  • Side effects
    • Vasomotor
    • Visual
31
Q

Hydrosalpinges treatment

A

Women with hydrosalpinges should be offered salpingectomy, preferably by laparoscopy, before IVF treatment because this improves the chance of a live birth.

32
Q

Reversal of sterilisation

A
  • No longer available on NHS
  • Consider IVF
33
Q

Male factor infertility

A
  • Urologist appointment if appropriate
  • IVF/ICSI
  • Intra-uterine insemination
  • Surgery
    • Reversal of vasectomy
    • Surgical sperm retrieval
  • Donor insemination
34
Q

Investigations for Azoospermia

A
  • History
  • Examination
  • FSH, LH, Testosterone, Karyotype, PRL
  • CF screen
35
Q

Azoospermia treatment

A
  • Surgical sperm retrieval
  • Microepididymal sperm aspiration
  • Testicular sperm extraction
36
Q

Unexplained infertility

A
  • Do not offer oral ovarian stimulation agents (such as clomifene) to women with unexplained infertility
  • Advise women with unexplained infertility who are having regular unprotected sexual intercourse to try to conceive for a total of 2 years (this can include up to 1 year before their fertility investigations) before IVF will be considered
  • Offer IVF treatment
37
Q

Access criteria for NHS IVF treatment in Scotland

A
  • both partners have no living children
  • both partners are non-smokers
  • BMI of female partner must be above 18.5 and below 30
  • neither partner has undergone voluntary sterilisation, even if sterilisation reversal has been self-funded
38
Q

Intracytoplasmic Sperm Injection (ICSI)

A
  • Injection of mature eggs with single sperm
  • Incubation overnight
  • Embryo transfer

Reproduction (34 decks)

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