Infertility Flashcards
Define infertility?
inability to conceive after 12 months of regular intercourse without contraception
Infertility affects what proportion of couples?
1:6
Primary vs secondary infertility?
primary= never had a child secondary= previously had a child but now unable
Describe the causes of hypothalamic pituitary failure and how that causes infertility?
Causes include: stress, excessive exercise, low BMI, brain tumours, head trauma, Kallman syndrome (genetic isolated GnRH deficiency), drugs e.g. steroids and opiates
Problem with not producing enough GnRH or dysregulation in pulsatility
will have low FSH, LH and amenorrhoea
Treatment of hypothalamic pituitary failure?
Should improve lifestyle factors e.g. gain weight
but ultimate treatment is pulsatile GnRH pump or FSH and LH daily injections
What is the commonest reason for ovulatory problems?
Polycystic ovarian syndrome
Hormone levels in PCOS?
normal GnRH and FSH, normal oestrogen usually, potential excess LH
Menstrual issues in PCOS?
oligo or amenorrhoea (although can be normal)
What is PCOS characterised by?
multiple small cysts within the ovary and by excess ovarian androgen production
What is PCOS associated with?
obesity, hyperinsulinaemia, insulin resistance and increased risk of T2DM, hypertension, hyperlipidaemia and increased CVS risk
Diagnostic criteria for PCOS?
2 or more of:
- clinical and/ or biochemical evidence of hyperandrogegism
- oligo/ anovulation
- polycystic ovaries on ultrasound scan
General treatment of PCOS?
weight loss, treatment of acne and hirsutism, treatment of infertility
Fertility treatment for PCOS?
OVULATION INDUCTION:
1st line is clomifene
2nd line is gonadotropin injections
3rd line is laparoscopic ovarian diathermy
Describe clomifene as fertility treatment for PCOS?
1st line: used on days 2-6 of the cycle, 70-80% ovulate, 30-40% conceive, letrozole is similar and may become first line as it requires less monitoring
Describe use of gonadotrophin injections for fertility treatment for PCOS?
2nd line: injections with recombinant FSH, 80% ovulate, 60-70% conceive but risks multiple pregnancy as well as hyperstimulation
Describe use of laparoscopic ovarian diathermy for fertility treatment for PCOS?
3rd line: 80% ovulate and no multiple pregnancies but it does risk ovarian destruction
Describe use of metformin for PCOS?
PCOS is linked to insulin resistance and metformin helps with that although the whole link and mechanism not really understood
metformin can improve clomifene resistance in those who don’t ovulate and make them more likely to conceive
Premature menopause is defined as ______
menopause before the age of 40
Hormones in ovarian failure?
Raised LH and FSH but decreased oestrogen
Causes of ovarian failure?
Turner syndrome (one X chromosome missing), other genetic conditions, autoimmune failure, surgery, radio/ chemotherapy, unknown aetiology
What therapy should someone with ovarian failure be on?
should be on combined HRT
Fertility treatment for someone with ovarian failure?
depends on stage of menopause, if peri-menopausal may get egg donor and hormonal treatment to maintain pregnancy, also option to adopt or foster
Describe some uterine or ovarian abnormalities which could cause infertility?
congenital uterine abnormalities fibroids endometrial polyps hydrosalpinx (blockage of tube with serous or clear fluid) ovarian cysts
Define azoospermia?
no sperm in ejaculate
Define asthenozoospermia?
% of progressive motile sperm below reference limit
Define oligozoospermia?
total number/ concentration of sperm is below that of reference limit
Define teratozoospermia?
% of morphologically normal sperm below the reference limit
If there are abnormal semen parameters then _____
male should be examined and should check LH, FSH, prolactin, testosterone, karyotype, check for CF carrier (as this can cause abnormalities in vas deferent), Y micro deletions
In male factors more than _________
50% of causes are unexplained
In GP appointment what initial investigations are done?
IN FEMALE:
- day 21 progesterone to establish ovulation
- rubella immunity
- chlamydia screen
- ensure smear up to date
- if amenorrhoeic or cycle lasts longer than 42 days also follicular phase bloods (LH, FSH, E2 (oestrodial)) , testosterone SHBG (sex hormone binding globulin), FAI and prolactin
IN MALES:
diagnostic semen analysis
Additional tests that may be done in female?
ultrasound scan
tests to look at tubal patency
Criteria for NHS access to ART? (9)
Stable relationship 2y (incl same sex)
Female age <40yrs (<42yrs)
Female BMI 18.5 – 30
Non-smokers (at least 3/12 pre-treatment)
No biological child from at least one of the couple
No illegal / abusive substances (incl methadone)
Neither partner to have been sterilised
Duration unexplained infertility 2y
Up to 3 cycles treatment
