Infertility Flashcards
What is the definition of infertility?
The inability of a couple to conceive after twelve months of regular intercourse without use of contraception
What would you ask the female during the history (infertility related)?
- 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
Which examinations would you perform on the female?
Weight and height (and then BMI), fat and hair distribution, galactorrhoea, abdo exam and pelvic exam
What are the signs of androgen excess?
Hirsutism and ancanthosis nigricans
How is androgen excess investigated
Testosterone, DHEAS > 700, adrenal CT and 17-OH progesterone
What would you look for on the female pelvic exam?
Masses, pelvic distortion, tenderness, vaginal septum and cervical abnormalities
Which baseline investigations would you do for the couple?
Female: rubella immunity, chlamydia, TSH, if regular periods then mid luteal progesterone, if irregular then day 1-5 FSH, LH, PRL, TSH and testosterone
Male: semen analysis
Which investigations would you do at the fertility clinic (female)?
Pelvic USS, physical exam, testing for ovulation, semen analysis repeat if required and tubal patency test
Which investigation is used for suspected tubal and uterine abnormalities in women without comorbidities?
Hysterosalpinography
What would you ask the male in his history?
- Developmental: testicular descent, changes in shaving frequency and loss of body hair
- Infections: mumps and STDs
- Surgical: varicocele repair and vasectomy
- Previous fertility
- Drugs/environmental: alcohol, smoking, anabolic steroids, chemo, raditiation and recreational drugs
- Sexual history: libido, frequency of intercourse and previous fertility assessment
- Chronic medical illness
What would you examine in the male?
Weight and height (+BMI), fat and hair distribution, abdominal, inguinal and genital (epididymis, testes, vas deferens and varicocele) exam
What is the cause of epididymitis?
STDs (chlamydia and gonorrhoea)
What is a varicocele?
Dilation of the pampiniform plexus
What effect does Klinefelter syndrome have on the testes?
Impaired spermatogenesis and testosterone deficiency with small testes and azoospermia
When should a couple be referred to the infertility clinic?
- After one year of trying unless there is a problem
- Problems: period irregularity, PMH, testicular problems, abnormal tests, HIV/Hep B, anxiety and age (35-45yrs after 6 months)
How do the WHO classify ovulation disorders?
- Group 1: hypothalamic pituitary failure
- Group 2: hypopathalamic-pituitary-ovarian dysfunction (predominately POS)
- Group 3: ovarian failure (POI)
What advice should women with group 1 ovulation disorders be given and what can you offer them?
They can improve their chance of regular ovulation, conception and uncomplicated pregnancy by:
- Increasing their body weight if their BMI is less than 19
- Moderating their exercise levels if high
You can offer them pulsatile administration of GnRH or gonadotrophins with lutenising hormone activity to induce ovulation
What are the features of polycystic ovary syndrome (POS)?
- Androgen excess: hirsutism and high testosterone levels
- Infrequent periods
- Polycystic ovaries on USS
What are the management options for ovulatory disorders?
- Treat underlying cause
- Weight loss/gain (BMI >18 and <35)
- Ovualation Induction: clomifene or gonadotrophins)
How does Clomifene work?
- Primary site of action is oestrogen receptors
- Secondary site is ovaries
- Mechanism: hypothalamus perceives a hypoestrogenic state causing the pituitary gland to release gonadotrophins
What is the treatment for hydrosalpinges and why?
Salpingectomy before IVF - improves chances of a live birth
What are the categories of azoospermia?
Testicular: normogonadotrophic, hypogonadism and hypergonadotrophic
Post Testicular: Iatrogenic, congenital and infective
What investigations would you do for azoospermia?
History, examination, FSH, LH, testosterone, karyotype, PRL and CF screen
