Infertility Flashcards
Infertility definition
• INABILITY of COUPLE to CONCEIVE AFTER 12 MONTHS REGULAR INTERCOURSE W/O CONTRACEPTIVE USE
Female Hx
- DURATION of INFERTILITY + HOW LONG HAVE THEY BEEN TRYING
- PREVIOUS CONTRACEPTION - some hormonal methods interfere w/ fertility
- FERTILITY in PREVIOUS RELATIONSHIPS
- PREVIOUS PREGNANCIES + COMPLICATIONS - if prior pregnancies present, then unlikely to be female infertility
- MENSTRUAL Hx - regular cycle means ovulation occurring
- MEDICAL + SURGICAL Hx - c-section (can leave scars in uterus), abdominal surgery for appendix rupture (tubes can be affected)
- SEXUAL Hx - freq., are they doing it the right way, previous/current STI
- PREVIOUS INVESTIGATIONS
- PSYCHOLOGICAL ASSESSMENT
Male Hx
- DEVELOPMENTAL - TESTICULAR DESCENT, CHANGE in SHAVING FREQ. (androgen reduction), LOSS of BODY HAIR (androgen reduction)
- INFECTIONS - MUMPS (TESTICULAR ATROPHY - reduces sperm count), STD (CHLAMYDIA, TESTICULAR TB)
- SURGICAL - VARICOCELE REPAIR, VASECTOMY
- PREVIOUS FERTILITY - PRIOR PREGNANCIES
- DRUGS/ENVIRONMENTAL - ALCOHOL, SMOKING, ANABOLIC STEROIDS, CHEMOTHERAPY (haematological cancer etc.), RADIATION, RECREATIONAL DRUGS
- Alcohol + smoking affects sperm production/function
- Anabolic steroids - can turn off inherent sperm production, some protein supplements are contaminated w/ testosterone
- SEXUAL Hx - LIBIDO (SEXUAL PROBLEM - androgen problem), INTERCOURSE FREQ., PREVIOUS FERTILITY ASSESSMENT (previous semen analysis normal + sudden abnormality - impending testicular failure)
- CHRONIC MEDICAL ILLNESS - ANY
Female Examination
- WGT.
- HEIGHT
- BMI (kg/m^2) - if too low may not be ovulating; if too high may be ovulating irregularly
- FAT + HAIR DISTRIBUTION - indication of underlying hormonal problems e.g. hirsutism (PCOS > Cushing’s syndrome, acromegaly, non-classic congenital adrenal hyperplasia (NCCAH))
- GALACTORRHOEA - prolactinoma
- ABDOMINAL EXAMINATION - SCARS, HAIR DISTRIBUTION
- PELVIC EXAMINATION - standard assessment, usually by USS - MASSES, PELVIC DISTORTION, TENDERNESS + PAIN (infection - acute/chronic), VAGINAL SEPTUM, CERVICAL ABNORMALITIES• FIBROIDS = PRESSURE SYMPTOMS, PERIOD PROBLEMS, INFERTILITY
Male Examination
- WGT.
- HEIGHT
- BMI (kg.m^2)
• FAT + HAIR DISTRIBUTION (hypoandrogenism) - increased body fat + decreased muscle mass may suggest androgen deficiency, loss of pubic, axillary, facial hair
- ABDOMINAL + INGUINAL EXAMINATION - HERNIA, HERNIA SCARS
- GENITAL EXAMINATION - EPIDIDYMIS, TESTES (normal volume, size, cysts, tumours), VAS DEFERENS, VARICOCELE
Female Baseline Investigations
- RUBELLA IMMUNITY - mandatory as it affects developing foetus, if vaccination given - wait for 1 month until starting fertility rx
- CHLAMYDIA - check for presence + treat, can be transmitted to pelvis
- TSH - if deranged, higher risk of infertility
- IF PERIODS ARE REGULAR = MID-LUTEAL PROGESTERONE LVLS (taken 7 days prior to expected period, checks for ovulation)
- IF IRREGULAR PERIODS = DAY 1-5 FSH, LH, PRL, TSH, TESTOSTERONE
Male Baseline Investigations
• SEMEN ANALYSIS
Female Investigations at Fertility Clinic
- PELVIC USS - abdo USS helpful if internal pelvic USS not poss.
- PHYSICAL EXAMINATION - BODY HAIR + FAT DISTRIBUTION
- OVULATION TESTING - if regular 26 - 35 day cycle, likely to be ovulating
- FREQ. + REGULARITY of MENSTRUAL CYCLES
- SERUM PROGESTERONE LVLS
- GONADOTROPINS (irregular menstrual cycles)
- TUBAL PATENCY TEST
- HYSTEROSALPINGOGRAM (HSG) - X-ray w/ contrast
- HyCoSy - USS
- LAPAROSCOPY
Male Investigations at Fertility Clinic
• SEMEM ANALYSIS REPEAT if REQ.
Tubal patency tests
HSG - women w/ no known co-morbidities e.g. endometriosis, previous ectopic pregnancy; for tubal occlusion
HyCoSy - can check myometrium, fibroids, polyps etc.
Laparoscopy - if tubes occluded on prior tests/want more accuracy
When to refer
• AFTER 1 YR TRYING
Or
• PROBLEM PRESENT ○ PERIOD IRREGULARITY ○ PMHx suggesting infertility e.g. ECTOPIC PREGNANCY, CANCER ○ TESTICULAR PROBLEMS e.g. AZOOSPERMIA * ABNORMAL TESTS * HIV/HEP B - can offer fertility rx to reduce transmission * ANXIETY - if pt. anxious can see earlier * AGE ○ < 35YRS - AFTER 1 YR ○ 35 - 45YRS - AFTER 6 MONTHS ○ > 45YRS - LITTLE CAN BE OFFERED (IVF unsuccessful)
Tubal Factor + Endometriosis
• SURGERY for HYDROSALPINGES BEFORE IVF rx
○ SALPINGECTOMY (preferably via LAPAROSCOPY) BEFROE IVF rx (improves chance of live birth) § Will make them sterile, but if kept, 50% less chance of successful pregnancy
- SURGERY vs. MEDICAL rx = ENDOMETRIOSIS, FIBROIDS
- REVERSAL of STERILISATION = no longer available on NHS, consider IVF
- IVF
Male Factor
- UROLOGIST APPT. if appropriate
- IVF/ICSI
- INTRA-UTERINE INSEMINATION - not for male factor infertility
- SURGERY - REVERSAL of VASECTOMY, SURGICAL SPERM RETRIEVAL (micro-epididymal sperm aspiration > testicular sperm extraction)
- DONOR INSEMINATION
INVESTIGATIONS for AZOOSPERMIA:
* Hx + EXAMINATION * FSH, LH, TESTESTORONE, KARYOTYPE, PRL * CF SCREEN
Unexplained Infertility
EXPECTANT vs. IVF
AGE, PREVIOUS PREGNANCY, DURATION of INFERTILITY
INVESTIGATE for 1YR (wait 1yr if young, if older age - straight to IVF)
Don’t give oral ovarian stimulants (e.g. clomifene) - don’t work as a standalone in unexplained infertility
If having regular unprotected sexual intercourse - try for 2yrs (up to 1yr prior to tests)
IVF rx
Group 1 ovulatory disorders
HYPOTHALAMIC PITUITARY FAILURE
* HYPOTHALAMIC AMENORRHOEA * HYPOGONADOTROPHIC HYPOGONADISM * LOW BODY WGT. STRESS, EXERCISE-RELATED AMENORRHOEA * CRANIOPHARYNGIOMA/OTHER TUMOURS affecting HYPOTHALAMUS * AMENORRHOEA combined w/ ANOSMIA (KALLMANN'S SYNDROME) * IDIOPATHIC
Can IMPROVE CHANCE of REGULAR OVULATION, CONCEPTION, UNCOMPLICATED PREGNANCY by:
* INCREASING BODY WGT. If BMI < 19 +/- MODERATING EXERCISE LVLS (if they undertake high lvls of exercise) * PULSATILE ADMINISTRATION of GnRH/GONADOTROPHINS w/ LH ACTIVITY to induce ovulation (recombinant - FSH; urinary - FSH + LH)
FUNCTIONAL - V. SLIM WOMEN, EXERCISE LOTS, LOW BMI/LOWER END of NORMAL BMI (prevents ovulation as body cannot sustain pregnancy)
