Infertility Flashcards
When do couples receive an infertility referral?
After 12 months of trying with no success or; period irregularity relevant PMH testicular problems Abnormal tests HIV/hep B Anxiety After 6 months of trying in over 35s
What is asked in a female history?
Duration of infertility Previous contraception and fertility Previous pregnancies and complications Menstrual history PMH Sexual history Psych assessment
What is looked at in a female exam?
Weight, height and BMI Fat and hair distribution Galactorrhoea ABdo exam Pelvic exam- masses, relic distortion, fixed retroversion, tenderness
What is asked in a male history?
Development- change in body hair or shaving frequency, testicular descent
Previous fertility
PMH- vasectomy, varicocele, testicular descent, chamo/radio
Occupational history
Sexual history
Previous investigations/treatment
Drugs and environment
What is done on a male exam?
Weight, height, BMI
Fat and hair distribution
Abdo and inguinal exam
Genital exam
What would a change in hair and fat distribution mean?
Problems with androgens- too much in females, too little in males
What baseline investigations are done for females?
Rubella immunity
Chlamydia
TSH
Testing for ovulation
Why is TSH tested for in females?
Subclinical hypothyroidism can cause issues with implantation
How is ovulation tested for in a woman w regular periods?
Mid luteal phase progesterone
Take sample 7 days before expected period
How is ovulation tested for with irregular periods?
Day 1-5 FSH, LH, PRL, TSH and testosterone
What tests are done for women at the fertility clinic?
Pelvic US
Physical exams
Tubal patency test- HyCoSy or laparoscopy
Test for ovulation- mid luteal progesterone or FSH and LH
What tests are done for males?
Computerised semen analysis
What would be considered a low sperm count?
<15 million sperm/ml
<39 million sperm per ejaculation
What is considered severe oligospermia?
<5 million sperm/ml
What are the types of ovulatory disorders?
Group 1- hypo-gonadotrophin, hypo-gonadic
Group 2- normo-gonadotrophic, norm-oestrogenic
Group 3- hyper-gonadotrophin, hypo-oestrogenic
What is the treatment of group 1 ovulatory disorders?
Optimise BMI
Reduce overexercise
What is an example of a group 2 ovulatory disorder?
Polycystic ovary syndrome
What is the diagnostic criteria for polycystic ovary syndrome?
2 of;
androgen excess
infrequent periods
US conformation
What are the signs and symptoms of androgen excess in PCOS?
Hirsutism
Moderately raised testosterone
Acanthosis nigricans
What is the treatment of PCOS?
Optimise BMI
Pharm- clomifene or gonadotrophins
What is clomifene?
Selective oestrogen receptor modulator
How does clomifene work?
Inhibits oestrogen receptos in hypothalamus, preventing negative feedback and leading to up-regulation of gonadotrophin, causing ovulation
What is the dose and course of clomifene?
Start 50mg, and adjust up to 150mg as necessary
Give for up to 6 cycles
What are the possible side effects of clomifene?
Ovarian hyperstimulation
Multiple pregnancy
Visual alterations
Vasomotor “flushes”
What are the indications to give gonadotrophin in PCOS?
No ovulation on clomifene
Ovulation but no pregnancy on clomifene
How many cycles can gonadotrophin be given for?
3-6 cycles
What are the signs and symptoms of an androgen secreting adrenal tumour?
Hirsutism
Acanthosis nigricans
What are the signs and symptoms of fibroids?
Pressure symptoms
Period problems
What type of fibroids affect fertility the most?
Submucosal- alter implantation
What are the common causes of female infertility?
Ovulatory disorders Androgen secreting adrenal tumour Prolactinoma Fibroids Endometriosis Tumours Sterilisation Unexplained
What causes epididymitis?
STIs
What are the conditions of male infertility re the vas deferens?
Cystic fibrosis mutations
Congenital bilateral absence
What are the conditions of male infertility re testes?
Testicular maldescent
Varicocele- dilation in pam-uniform plexus of veins
What is hypospadias?
Urethral meatus on penis not in usual location
What are the causes of azoospermia?
Testicular- normogonadotrophic, hypogonadism, hypergonadotrophic
Post testicular- iatrogenic, congenital, infective
What is the commonest cause of hypogonadism?
Klinefelter syndrome
What investigations are done for azoospermia?
History and exam
FSH, LH, testosterone and prolactin
Karyotype
CF screen
What is the management of azoospermia?
Surgical sperm retrieval
