Infertility Flashcards
How successful are couples at getting pregnant with regular intercourse?
84% of couples will conceive within 1 year and 92% within 2 years with regular sex.
What percentage of infertility problems are due to male problems?
Male factors – 30%
What male problems can lead to infertility?
- Semen abnormality 85% – OATS (all parameters low), testis cancers, drugs (alcohol, nicotine), genetic and varicocele.
- Azoospermia 5% – pretesticular (steroid use, hypogonadotrophuc hypogonadism), pituitary adenoma
- Immunological 5% – antisperm antibodies, idiopathic, infection or unilateral testicular obstruction
- Coital dysfunction 5% – retrograde ejaculation, hypospadias, phimosis and failure to ejaculate
What percentage of infertility problems are due to female problems?
Female factors - 70%
What are the common female factors that lead to infertility?
Ovulation failure – 20%
Tubal damage – 15%
Other – 15%
Unexplained – 20%
When should investigations into infertility take place?
Investigate after 1 year, earlier if: women >35, a/oligomenorrhoea, past PID, undescended testes or cancer treatment
How should the woman in a couple be investigated for infertility problems?
Ovulating – check for high progesterone at 21 days or 7 days prior to next period
<16mmol/l – repeat if consistently low refer to specialist
16-30mmol/l – repeat
>30mmol/l = ovulation
BMI PCOS – Rotterdam criteria TFTs* Check FSH (day 2-5 - <10Iu/L), LH (day 2-5 - <10Iu/L), and prolactin Rubella status
Tubal patency – Hysterosalpingography, Hysterosalpingo-contrast sonograph or Laparoscopy and dye test (gold standard)
*There is an overlap between TSH, LH and FSH as they all share a subunit. As such Thyrotoxicosis driven by excess TSH can cause Amenorrhea as TSH may block the receptors for FSH and LH.
What questions should you ask a woman about for infertility problems?
Important to ask regarding previous surgery, STIs, coital frequency and problems, previous pregnancies or miscarriages, alcohol smoking, recreational and prescription drugs.
Examine for endocrine disorders, exclude obvious pelvic pathology, check cervical smear and screen for STIs.
What questions should you explore in a history for infertility with a man
Important to ask regarding previous surgery, STIs, coital frequency and problems, mumps, ED, alcohol smoking, recreational and prescription drugs.
How should a man with potential infertility problems by investigated and examined?
Examine – any gynaecomastia and check normal genitals
BMI Semen analysis – normal results: • Volume >1.5mL • Concentration > 15 x 10^6/mL • Progressive motility > 32% • Total Motility > 40% Azoospermia = no sperm, oligozoospermia = reduced number of sperm
Check FSH – elevated in testicular failure
Check testosterone and LH is suspecting androgen insufficiency
Karyotype – 47XXY
Cystic Fibrosis screen
What management options are there for females with infertility problems?
Lifestyle Modifications
• Folic acid and healthy diet
• Reduce weight
• Regular sexual intercourse but avoid timing it – stressful and may miss ovulation
• Cessation of smoking, drinking and drugs
Ovulation induction • Treat PCOS • Antioestrogens – Clomiphene (increase multiple pregnancy) • Insulin sensitizers – metformin • Gonadotrophins or pulsatile GnRH • Laparoscopic ovarian diathermy
Tubal patency
• Treat endometriosis
• Tubal surgery
Assisted reproduction – IUI or IVF
What management options should be considered in a male with infertility problems?
Reduce weight
Consider multivitamin containing, zinc, selenium and vitamin C
Regular sexual intercourse
Cessation of smoking
Stop antispermatogenic medication – anabolic steroids, antifungals and sulfasalazine
Stop antiandrogenic – cimetidine or spironolactone
Assisted reproduction – IUI or IVF
What causes erectile dysfunction?
Usually due to alcohol, smoking or diabetes
Can be caused by drugs – alpha or beta blockers, antidepressants, diuretics and antipsychotics
How should erectile dysfunction be investigated?
Calculate 10-year cardiovascular risk
Free testosterone levels between 9 and 11 am – if low or borderline then repeat with FSH and LH and prolactin levels and refer to endocrinology if these are abnormal.
How is erectile dysfunction managed?
Manage with phosphodiesterase 5 inhibitors – sildenafil
