Infertility Flashcards
What is the definition of infertility?
Failure to achieve clinical pregnancy after 12 months or more of regular unprotected sex, in a couple who have never conceived a child
How are primary and secondary infertility defined?
Primary - couple have never conceived Secondary - couple have previous pregnancy - includes stillbirth, miscarriage and ectopic
What are the three categories of male infertility?
Idiopathic (most common)
Obstructive
Non-obstructive
What are the main causes of obstructive male infertility?
Cystic fibrosis - congenital bilateral absence of the vas deferens
Vasectomy
What are the endocrine features of obstructive male factor infertility?
Normal LH, FSH and testosterone
How can non-obstructive causes of male infertility be classified?
Congenital - cryptorchidism (undescended testes) Chromosome abnormality Infection Endocrine Testicular tumours Sperm abnormalities
Which chromosome abnormalities cause male infertility?
Klienfelter’s syndrome - 47 XXY
Microdelections of the Y chromosome
Robertsonian translocation
Which infections can cause male infertility?
Mumps orchitis (usually temporary) STIs
What are the endocrine causes of male infertility?
Pituitary tumours Hypothalamus disorders Thyroid disorders Diabetes Congenital adrenal hyperplasia Steroid abuse
How can female factor infertility be classified?
Anovulatory
Tubal factor
What are the causes of anovulatory infertility?
Hypothalamic: - anorexia - bulimia - excessive exercise Pituitary: - hyperprolactinaemia - pituitary adenoma - Sheehan's syndrome Ovarian: - PCOS - premature ovarian failure
Others:
- CKD
- hormonal medications
- congenital adrenal hyperplasia
What are some of the causes of premature ovarian syndrome?
Turner's syndrome Fragile X syndrome Chemo or RT Autoimmune Often unknown
What are the causes of tubal factor infertility?
Infective:
- PID
- appendicitis or intra-abdominal abscess
- iatrogenic e.g. IUD insertion, hysteroscopy, HSG
Non-infective:
- endometriosis
- salpingitis isthmica nodosa (SIN) - scarring following inflammation
- uterine polyps or fibroids blocking tube
How is PID treated if diagnosed at the time of infection?
Metronidazole + Ofloxacin
Which tests are done initially for infertility?
History + examination Pelvic exam of female Endocervical swab for chlamydia + smear if due TV USS Semen analysis - if abnormal, male genital exam Investigate tubal patency - laparoscopy - HSP Test for ovulation: - mid-luteal progesterone Chromosome analysis
What are you looking for on examination of male genitals?
Descended testes Bilateral vas deferens Bilateral epididymus Varicocele or other scrotal swelling Testicular volume within normal range (12-25 ml) Signs of gynaecomastia
Which parameters are measured on semen analysis?
Volume of semen pH Concentration Total sperm number Total motility Progressive motility Morphology
Which factors need to be adhered to in order to keep semen analysis accurate?
Complete sample obtained Analysed within 1 hour of production Kept at body temperature Man in good health Abstain from ejaculation for 72 hours Avoid caffeine and alcohol in days leading up to test
What are the guideline for testing tube patency?
Laparoscopy if there is possible tubal disease or pelvic inflammation
- e.g. PID or known previous pelvic pathology such as ectopic
Hysterosalpingogram if:
- no known risk factors for tubal/pelvic disease
- laparoscopy contraindicated e.g. obesity, Crohns
What is the definition of assisted conception treatment (ACT) and what are the different types?
Treatment for infertility which involves gametes outside the body
- donor insemination
- intra-uterine insemination (IUI)
- in vitro fertilisation (IVF)
- intra-cytoplasmic sperm injection (ICSI)
What are the indications for ACT?
Couples with fertility issues where at least one partner doesn’t have any biological children
Same sex couples
Fertility preservation
- cancer treatment
- gender reassignment surgery
To avoid transmission of BBVs e.g. HIV
Preimplantation diagnosis of certain inherited disorders
How many cycles of IVF/ICSI can couples receive on the NHS?
3
What are the criteria for IVF on the NHS?
In relationship for > 2 years
Non smoking for 3 months before treatment + during treatment
No alcohol
Female BMI between 18.5 to 30
Neither undergone voluntary sterilisation
Female up to date smears, screened for BBV and rubella immunised
How does IVF on NHS differ for women age 40-42?
Only 1 full cycle offered
What are the indications for intra-uterine insemination?
Sexual dysfunction
Female same sex (donor sperm)
Male same sex (surrogacy)
What are the 5 steps of IVF/ICSI?
- Down regulation
- Ovarian stimulation
- Oocyte collection
- Fertilisation
- Embryo transfer
What happens in down regulation?
GnRH analogues/agonists used to induce temporary menopause
What happens during ovarian stimulation?
Gonadotropin hormone injections given for 10-14 days to induce follicular development + oocyte maturation
GnRH agonist used to prevent LH surges
HCG injection administered to stimulate final maturation of oocytes
What happens during oocyte collection?
US guided needle aspiration of oocytes –> embryology lab
What happens during fertilisation?
IVF:
- sperm + oocyte placed in petri dish
ICSI:
- one sperm immobilised and injected into oocyte
What happens during embryo transfer?
Normally one (maximum two) inserted into uterus
Progesterone suppositories used for 2 weeks
When does embryo transfer take place?
Day 5 usually (blastocyst stage)
What are the indications for IVF?
Unexplained infertility > 2 years Pelvic disease (tubal, endometriosis, fibroids) Anovulatory infertility (after failed ovulation induction)
What are the indications for ICSI over IVF?
Severe male factor infertility
Previous failed fertilisation with IVF
Pre-implantation genetic diagnosis
When is surgical sperm aspiration indicated and where is it aspirated from?
Azoospermia (little or no sperm)
- if obstruction –> taken from epididymus
- if non-obstructive –> taken from testicular tissue
What are the complications of ACT?
Ovarian hyperstimulation syndrome (OHSS) Multiple pregnancy Ectopic pregnancy Increased risk of miscarriage Surgical risk from oocyte collection - infection, bleeding, damage to viscera
What causes OHSS?
Large number of follicles + high estradiol levels –> release of inflammatory markers and vasoactive substances
–> fluid shift in abdomen
What are the symptoms of OHSS?
Bloating
Abdominal distension
Nausea and vomiting
What are the complications of severe OHSS?
VTE
ARDS
How is OHSS managed?
Before embryo transfer: - elective freeze - single embryo transfer After embryo transfer: - monitor with USS and blood tests - reduce VTE risk (fluids, stockings, fragmin) - analgesia Admit if requiring IV fluids, intensive monitoring or paracentesis
When is the blood test for ovulation done?
Mid luteal progesterone
–> 7 days before end of cycle
e.g. day 21 of 28 day cycle
day 28 of 35 day cycle
