Infertility Flashcards
What is the epidemiology of infertility?
Defined as failure to conceive after 1yr of trying
C.15% of couples
Considerable psychological distress
What are the causes of infertility?
Unexplained - 25%
Female:
Ovulatory - 25%
Tubal - 20%
Uterine - 10%
Male - 30%
Decreases with age up until menopause; male can still remain fertile into older age but poorer quality sperm
Also increased risks of babies with genetic abnormalities e.g. Down’s; increased maternal risks
What is the initial management of a couple presenting with infertility?
Good sexual Hx:
Ovulating? Frequency? Type of sex? STIs? Previous children? Gynae Hx etc
Reassurance - 80% will conceive in 1st year, half of remaining will conceive in the second year
Refer after 1yr
Early referral if:
Female age >35
Known or suspected problem - menstrual disorder, Hx abdo/pelvic surgery, PID, STD; abnormal pelvic exam
Male: Hx genital pathology, urogenital surgery, STD, systemic illness, abnormal genital exam
What is the preconception advice for couples trying?
Sex 2-3x per week
Folic acid - 0.4mg PO OD, 5mg if high risk e.g. DM
Smears up to date?
Rubella vaccinated for?
Smoking cessation, drug and alcohol use cessation (both partners)
Optimising preexisting medical conditions
Weight - need to be between 19-30 BMI (greater also has lower success with IVF)
How do you initially investigate infertility?
Ovulation/ovarian function: Progesterone - day 21/mid-luteal phase, to check for ovulation = level >30 for; may need to be done serially if long or irregular cycles FSH - day 5 - <4 = high response, >8.9 = low response Antral follicle count (AFC) - <4 = low response, >16 = high response Antimullerian hormone (AMH) - <5.4 = low response, >25 = high response
Semen analysis: Count = >15mil/ml Motility = >40% Total = >39mil Repeat if abnormal (if count <5ml - FSH, LH, PRL; karyotype e.g. klinefelters; CF? Possible biopsy or imaging)
Possible: TFT (hypothyroid) Prolactin (prolactinoma, antipsychotics) Rubella antibodies Smears Swabs
What is tubal patency testing? How is tubal disease managed?
In specialist clinics, after initial testing has proved normal
HyCoSy (Hysterosalpingo Contrast Sonography):
It is conducted by forcing an aqueous fluid up the fallopian tube to provide a contrast medium for ultrasound
To detect whether the fallopian tubes are damaged or blocked
Alternatives:
HSG (Hysterosalpingography) - involves placing an iodine-based dye through the cervix and taking x-rays
Laparoscopy and Dye, without the use of X-rays
Tubes may not be patent because of:
Infection - chlamydia, gonorrhoea
Endometriosis
Adhesions, sterilisation
Management: Adhesiolysis Reversal of sterilisation Tubal catheterisation IVF
How do you treat male infertility?
Manage risks: Heat - occupation is important e.g. truck drivers have hot squashed balls Underwear Smoking, alcohol Weight
Mild - artificial insemination
Moderate - IVF
Severe - intracytoplasmic sperm injection (sperm injected directly into egg)
Also:
Correction of epididymal blockages, vasectomy reversals, gonadotropins (if hypothalamic hypogonadism), bromocriptine (if prolactinoma - is a DA agonist)
Donor insemination
Adoption
What are the different aetiologies of anovulatoin and how do you manage them?
Group 1: low FSH/LH
Aetiology: Stress, weight loss, over exercise, Kallman’s
Management: FSH + LH supplementation, GnRH pump, normalise weight
Group 2:
Mostly PCOS
Treat with ovulation induction - clomiphene
Other:
Prolactinoma - give bromocriptine
What are the types of assisted conception?
Ovulation induction - clomiphene
IVF: Intracytoplasmic sperm injection Embryo freezing Assisted hatching Embryo transfer strategies - <37yrs: 1st cycle, put back one, 2nd put back 1-2; 37-39yrs - put back 1-2; 40-42yrs - put back two
Donor: Insemination Egg Embryo Surrogacy
What are some risks of IVF?
Multiple pregnancy
Miscarriage
Ectopic
Ovarian hyperstimulation syndrome - presence of multiple luteinised cysts in ovaries raises concentrations of oestrogens progesterones and vasoactive substances that lead to the loss of fluid into the intravascular compartment - abdo pain/bloating, N+V, ascites, oliguria, VTE, ARDS
Possible increased risk of ovarian cancer
What patient factors affect the success of IVF?
Age Cause of infertility - fibroids may lead to lower pregnancy rates (myomectomy may be useful for improving) Previous pregnancies Duration of infertility Number of previous attempts Specific medical conditions
Who gets access to IVF on the NHS?
If 2 years of regular unprotected sex + under age of 40yrs
OR
Who have had 12 cycles of artificial insemination
Give these women 3 cycles of IVF or stop once age 40
If age 40-42 then 1 full cycle
Anything done privately (1 cycle costs c.£5000+) counts against the total you are allowed on the NHS
Also: No previous children BMI 19-30 Non smoker Other local guidelines
