Infertility Flashcards
what are some causes of infertility?
- unexplained
- ovulatory
- male
- uterine/peritoneal
- tubal
what are the criteria for early referral for infertility treatments?
Female Age > 35 Menstrual disorder Previous abdominal / pelvic surgery Previous PID / STD Abnormal pelvic examination
Male Previous genital pathology Previous urogenital surgery Previous STD Systemic Illness Abnormal genital examination
what is the preconception advice?
Intercourse – 2-3 x week Folic acid – 0.4mg (5mg high risk) Smear Rubella Smoking – cessation services Pre-existing medical conditions Drug history (prescribed / recreational) Environmental / occupational exposure Alcohol (women none) Weight (BMI 19 – 30)
what reproductive disorders are associated with obesity?
PCOS miscarriage infertility obstetric complication lower ART success
what investigations would you perform for fertility?
ovulation/ovarian function
semen quality
tubal patency (+uterus)
tubal patency - HyCoSy or Hysterosalpingography
how do you check for ovulation?
mid-luteal progesterone
how do you test for ovarian reserve?
FSH >8.9 - low response <4 - high response Antral Follicle Count (AFC) <4 - low response >16 - high response Antimullerian Hormone (AMH) <5.4 - low response >25 - high response
what would you do to investigate male fertility?
semen analysis
- count, motility, morphology, total
repeat if abnormal
further investigation:
- secondary sex characteristics, testicular size
- endocrine - FSH, LH, prolactin
- karyotype
- CF screen
what initial investigations should GP order before referring to Fertility clinic?
Hormone profile (D2 FSH, D21 Prog) TFT, Prolactin – if indicated Rubella Smear Swabs Semen analysis
what further investigations would you perform for female infertility?
HSG (hysterosalpigography) or HyCoSy
Hysterosalpingo Contrast Sonography
USS
how do you manage male infertility?
if mild - IUI
moderately abnormal - IVF
severe - ICSI
azoospermia - surgical sperm recovery, donor insemination
correction of epididymal block
vasectomy reversal
LIFESTYLE FACTORS - heat - occupation? tight underwear, smoking, alcohol, occupation exposure, weight
what are some causes of anovulation?
Loe FSH/LH/E2 - stress, weight loss, exercise, Kallmans - treat with FSH and LH, GnRH pump and normalise weight
adenoma - prolactin - treat with bromocriptine
Sheehan’s - treatment - FSH and LH
PCOS - normalise FSH, USS, androgens - ovulation induction - clomifene
menopause - high FSH - treatment egg donor
what criteria i used for PCOS ?
Rotterdam Criteria 2003 - 2 out of 3 criteria Anovulation / oligo/amenorhoea Polycystic ovaries on scan (TVS) One ovary >12 small follicles Vol > 10cc Raised Androgens Clinical or biochemical exclude adrenal cause)
how can you treat infertility cause by PCOS?
Normalise weight Clomifene (or Tamoxifen) Up to 6 cycles (NICE 2013) Monitor (Progesterone & USS) Inform of multiple preg rate (6-8%) >12 months ? Ovarian Ca risk Metformin Less effective than clomifene alone Less effective in obese May help if clomifene resistant GI side effects
If this fails you can perform laparoscopic ovarian drilling or gonadotrophin ovulation induction
what are the sites and causes of tubal disease?
sites - proximal, distal, adhesions (ovarian or tubal)
causes
- infections
- endometriosis
- adhesions
- sterilisations
