Infertility Flashcards
Incidence of infertility
1 in 7 couples report infertility problems
Infertility definitions
The inability of a couple to conceive after 12 months of regular intercourse without use of contraception.
Chance of conception
- 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%).
Female history
- 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
Female examination
- Weight
- Height
- BMI (kg/m2)
- Fat and hair distribution
- Galactorrhoea
- Abdominal examination
- Pelvic examination
Clinical measurement of androgen excess
Ferriman Gallwey Score
Biochemical measurement of androgen excess
- 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
What is looked for on a pelvic examination?
- Masses
- Pelvic distortion
- Tenderness
- Vaginal septum
- Cervical abnormalities
Fibroid symptoms
- Pressure symptoms
- Period problems
- Infertility
Baseline female investigations
- 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).
Baseline male investigations
semen analysis
Investigations at Fertility Clinic
- Pelvic Ultrasound
- Physical examination
- Testing for ovulation
- Tubal patency test
- Semen analysis repeat if required
Assessment of ovulation in women who are concerned about their fertility.
- 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.
Assessment of ovulation in women who are undergoing investigations for infertility (even if they have regular menstrual cycles)
Mid luteal progesterone ( 7 days prior to expected period) to confirm ovulation.
Assessment of ovulation in women with prolonged irregular menstrual cycles.
- 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 ).
Investigation of suspected tubal and uterine abnormalities
hysterosalpingography (HSG)
Male history
- 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
Male examination
- Weight
- Height
- BMI (kg/m2)
- Fat and hair distribution (hypoandrogenism)
- Abdominal and inguinal examination
- Genital examination
- Epididymis
- Testes
- Vas deferens
- Varicocele
Varicocele
- 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)
Klinefelter syndrome
One of the most common causes of primary hypogonadism with impaired spermatogenesis and testosterone deficiency.
Classification of ovulatory disorders
- 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).
WHO Group I ovulation disorders
- 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
Which criteria is used to diagnose polycystic ovary syndrome?
The Rotterdam criteria
Rotterdam criteria
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
Symptoms of Polycystic ovary syndrome
HAIR
- Hirsutism
- Amenorrhoa
- Irregular periods / Increased weight
- Reduced fertility and miscarriage
Investigations for polycystic ovary syndrome
- General blood tests
- FBC, U&E, TFTs
- Specific blood tests
- Androgen levels, SHBG (sex hormone binding globulin), LH, FSH, prolactin
- Radiology
- Transvaginal ultrasound scan
Treatment for polycystic ovary syndrome
- Conservative
- Weight loss
- Medical
- Hirsutism - oral contrceptive pills with an anti-androgen effect (eg Yasmin)
- Subfertility - metformin may help
- Inducing ovulation (eg clomifene)
Complications of polycystic ovary syndrome
- Infertility
- Type 2 diabetes mellitus
- Gestational diabetes
- Depression
- Increased weight
Ovulation induction
- Clomiphene
- Gonadotrophins
- GnRH
Clomifene: clinical use
- 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
Hydrosalpinges treatment
Women with hydrosalpinges should be offered salpingectomy, preferably by laparoscopy, before IVF treatment because this improves the chance of a live birth.
Reversal of sterilisation
- No longer available on NHS
- Consider IVF
Male factor infertility
- Urologist appointment if appropriate
- IVF/ICSI
- Intra-uterine insemination
- Surgery
- Reversal of vasectomy
- Surgical sperm retrieval
- Donor insemination
Investigations for Azoospermia
- History
- Examination
- FSH, LH, Testosterone, Karyotype, PRL
- CF screen
Azoospermia treatment
- Surgical sperm retrieval
- Microepididymal sperm aspiration
- Testicular sperm extraction
Unexplained infertility
- 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
Access criteria for NHS IVF treatment in Scotland
- 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
Intracytoplasmic Sperm Injection (ICSI)
- Injection of mature eggs with single sperm
- Incubation overnight
- Embryo transfer
