Infertility Flashcards
Define infertility
The inability to conceive after 12 months of regular, unprotected intercourse
What is primary infertility?
When there has been no pervious pregnancy
What is secondary infertility?
Had pregnancy previously from current or previous relationship
What percentage of couples in the general population will conceive within 1 year if the woman is less than 40?
80%
50% of the remaining will conceive in second year (ie 90% of total)
95% at 3 years
Are women born with a finite number of oocytes?
Yes : 1-2 million
Approx 400,000 at puberty
How many oocytes do women approx have at menopause?
Less than 1000
How many mature oocytes are released during reproductive life?
Around 500
Decline in fertility is directly related to…
Reducing oocyte population and egg’s inherent quality
There is a small fall in fecundity rates from …
Approx 31 years old
When is there a pronounced fall in fecundity rates ?
From 37 and steep fall after 40
As a women gets older, there is an increased risk of…
Spontaneous miscarriage
Genetically abnormal offspring
What causes of infertility are there?
Ovulation defects 25% Male factor 30% Tubular disease 20% Unexplained 25% Endometriosis (small percentage) Uterine factors (small percentage)
What might anovulation by caused by?
PCOS
Weight related: BMI>30 or <18
Ovarian failure - natural or secondary to chemotherapy or RT
Hyperprolactinaemia
What can cause tubal disease?
PID
Pelvic surgery
Endometriosis
Anything that blocks the tubes and their function
What should be discussed during history (female)?
Age
Duration of infertility
Have they had previous pregnancies, does either partner have children
Menstrual cycle - regularity, flow, associated pain, IMB, PCB
History of STIs
Previous surgery, especially tubal or for ectopic pregnancy
ask about smoking and alcohol (both reduces fertility)
What should be done on examination (female)?
BMI - obesity has adverse effects on fertility
Body hair distribution, acne - signs of hyperandrogenism
Galactorrhoea
If history of primary or secondary amenorrhoea, check secondary sexual characteristics
Pelvic examination and speculum - take swabs and do cervical smear if due
What should be discussed during history (male)?
General health
Alcohol and smoking - both affect sperm quality
Previous surgeries especially hernia., undescended testes
Previous infection e.g mumps, TB
Sexual dysfunction - erectile, ejaculatory
What should be done on examination (male) if necessary?
Scrotum for varicocele
Testicular size and position
Prostate for chronic infection
What baseline investigations should be done in primary care?
Follicular phase: LH, FSH (day 2-4) Luteal phase progesterone (day 21) Rebella status Cervical screening if not done Chlamydia screening (before checking tubal patency to precent ascending infection)
Depending on history:
Prolactin level
TFTs
Testosterone/ SHBG
What secondary care tests should be done?
Pelvic USS prior to laparoscopy if suspecting ovarian pathology or uterine abnormality
Testing for tubal patency:
Hysterosalpingography HSG - she injected through cannula in cervix to demonstrate uterine anatomy - radiological images taken
Or laparoscopy and dye test (gold standard for assessing tubal patency) - methylene blue dye injected through cervix whilst tubes visualised with a laparoscope
When should a diagnostic lap and dye test be done?
Used first line if strong suspicion of tubal abnormality or need laparoscopy for other reasons.
- previous PID history, endometriosis or previous surgery
Used second line if HSG abnormal
What baseline investigations should be done for men?
Semen analysis x2
If abnormal : make lifestyle changes e.g reduce/ stop smoking and alcohol and repeat after 3 months
If aspermia or oligospermia :
FSH, LH, testosterone
USS - seminal vesicles and assess prostate
In terms of management, what lifestyle factors should be addressed?
Weight loss if necessary
Healthy diet
Stop smoking and recreational drug use
Reduce alcohol to less than recommended limit
Regular exercise
Folic acid (woman)
Regular intercourse every 2-3 days
Avoid ovulation monitors - stress and no evidence for benefit
Couples who time intercourse for day of ovulation might be too late, ideally there should be some sperm available for whenever fertilisation occurs
What methods are there for ovulation induction?
Weight loss or gain
Clomifene citrate 50mg days 2-6 of cycle
If not suitable or unsuccessful: gonadotrophins (pulsatile GnRH)
How is hyperprolactinaemia treated?
Dopamine agonist
How can tubal disease be treated?
Surgical techniques - reconstruction, catheterisation
IVF
What are the indications for IVF?
Tubal disease Male factor subfertility Endometriosis Anovulation not responding to Clomifene Due to maternal age Unexplained for more than 2 years
If infertility is due to male factor what can be done?
IVF
Intracytoplasmic sperm injection (ICSI)
Donor sperm if aspermia
When defining what is regular (for sexual intercourse) for those trying to get pregnant, what should you advise?
Every 2-3 days
When is donor insemination used?
When the male partner has azoospermia with failed surgical sperm retrieval
High risk of transmitting a genetic disorder
High risk of transmitting HIV
Woman with no (male) partner
What is intracytoplasmic sperm injection? (ICSI)
When sperm is taken out of ejaculate or surgically from testis or epididymis and injected directly into the egg
When is ICSI used?
When semen parameters severely abnormal
Failed fertilisation has occurred with IVF cycles
Concern that genetic mutations (especially Y chromosome deletions) will be propagated by transmission to offspring
When is intrauterine insemination used? (IUI)
In mild male factor subfertility
Coital difficulties - physical disability or psychosexual problem
If it’s not safe to have unprotected sex e.g HIV
Same sex couples
What is the difference between IUI and IVF?
In IUI the highest quality sperm / donor sperm selected and injected into uterus where they are left to fertilise egg naturally.
In IVF the eggs are removed from the body and fertilised in the lab.
IUI less invasive procedure and involves fewer drugs.
IUI is less expensive than IVF, but also less successful
When will IUI not be appropriate?
If blocked tubes, severe endometriosis, low quality eggs or low number,
How does Clomifene work?
An anti oestrogen
Increased endogenous FSH via neg feedback to pituitary
What is the multiple pregnancy rate with clomifene?
10%
What side effects can clomifene cause?
Hot flushes
Labels mood
If severe headache or visual disturbance- stop immediately
How many cycles should clomifene be used for?
6-12 cycles
Before specialist prescribes clomifene, what should they confirm first?
Tubal patency
Semen count normal or near normal
BMI <30
What cancer does clomifene have a possible link with?
Ovarian cancer
When taking clomifene, what type of monitoring is required?
Follicular monitoring by US - risk of hyperstimulation
