Infertility Flashcards
- A basic understanding of the female reproductive cycle
- Knowledge of history and examination of sub-fertile couple
- Knowledge of investigation pathways in male and female infertility
- An understanding of treatment options in male and female infertility
- An introduction to the technology of assisted conception
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Infertility is defined as inability to conceive after how long of trying
12 months
Questions to ask an infertile female
Duration of infertility Contraception used in the past Fertility in previous relationships Previous pregnancies Menstrual history - last period, frequency, regularity etc PMH Sexual history Psychological assessment
Examination of an infertile female
Weight
Height
BMI
Fat and hair distribution – any underlying endocrine problem
Galactorrhoea - milk secretion unrelated to breastfeeding
Abdominal examination
Pelvic examination
Causes of hirsutism
Polycystic ovarian syndrome
Congenital adrenal hyperplasia
Cushing’s syndrome
Acromegaly
Pelvic examination of females should look at what things
Masses Tenderness Any vaginal septum Cervix abnormalities Fibroids - use USS
Baseline investigations for infertile females
Rubella immunity - must be immune to get fertility treatment
Chlamydia
TSH
If periods regular - mid-luteal progesterone
If periods irregular - day 1-5 FSH, LH, TSH, testosterone
Baseline investigation for infertile male
Semen analysis
How to assess whether females are ovulating or not
Frequency and regularity of menstrual cycle - if regular then likely ovulating
Serum progesterone in mid-luteal phase (usually day 21 or 28) to confirm ovulation even if cycles are regular
If cycles irregular
- serum progesterone later in the cycle
- FSH & LH
Investigations for tubal occlusion
Hysterosalpingography (HSG) - XR
Hysterosalpingo-contrast-sonography (HyCoSy) - US
Laparoscopy - more accurate as above 2 are just screening tests
Questions to ask an infertile male
Previous fertility
Any developmental problems
-cryptorchidism, loss of body hair
PMH
- infections - mumps, STIs
- chronic illnesses
Surgical history
-varicocele, vasectomy
Drug history
-alcohol, smoking, steroids, chemo etc
Sexual history
-sex drive, frequency of intercourse
Examination of an infertile male
Weight Height BMI Fat + hair distribution - look out for androgen deficiency Abdo + inguinal examination Genital examination -testicular size (ideally 15+ml)
When should the GP refer you to fertility clinic
After 1 year of trying OR If there's a problem with -period regularity -PMH -testicular problems -HIV -abnormal blood tests -older age
WHO classifies ovulation disorders into 3 groups
Group I: hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism)
Group II: hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome)
Group III: *ovarian failure (POI – premature ovarian insufficiency)
*term not used anymore
How does polycystic ovary syndrome affects fertility
Failure to ovulate an egg each cycle or irregular ovulation
Treatment options to induce ovulation if you have ovulatory disorders
Clomifene - block oestrogen receptors in AP leading to increased FSH secretion
Gonadotrophins - FSH injection
-only if clomifene doesn’t work or ovulation leads to unsuccessful pregnancy
Treatment options for females with tubal factor infertility (diseases, damage, scarring or obstructions in thefallopian tubes. e.g. PID, STIs, endometriosis)
Salpingectomy (removal of fallopian tube) ideally before starting IVF
Treatment options for male factor infertility (presence of abnormal semen parameters [semen volume, sperm concentration, motility, morphology of sperm] in themalepartner of a couple unable to achieve conception after 1 year of unprotected intercourse)
Hormone treatment - gonadotrophin
Assisted reproductive techniques
- Intra-uterine insemination
- IVF +/- intracytoplasmic sperm injection
Donor insemination
Define azoospermia
semen contains no sperm
Treatment options for females with unexplained infertility
DO NOT OFFER ORAL STIMULANTS, e.e. clomifene
Intra-uterine insemination
List 4 types of infertility problems
Tubal factor infertility
Male factor infertility
Ovulatory disorders
Uxexplained infertility
If individual treatment doesn’t work then try IVF
List assisted conception/reproductive techniques
Intra-uterine insemination -inserting sperm into uterus
IVF
Intracytoplasmic sperm injection (ICSI) - single sperm injected straight into a single egg in the lab and the resulting embryo is transplanted into uterus
Donor sperm of eggs
3 features of polycystic ovary syndrome
Irregular periods – which means your ovaries do not regularly release eggs
Excess androgen – high levels of male hormones in your body, which may cause excess facial or body hair
Polycystic ovaries – ovaries become enlarged and contain many follicles that surround the eggs (despite the name, you do not actually have cysts)
Treatment of those with polycystic ovary syndrome desiring fertility
Weight loss +/- metformin (to control weight)
Ovulation induction - clomifene (1st line), gonadotrophin (2nd line)
If all above fails –> IVF
