infertility Flashcards
define infertility
Defined as the inability to conceive after 12 months of regular unprotected intercourse
causes of infertility
Male factor (30%) - failure of sperm production - previous radiotherapy, infection
fallopian tubes not patent
- infection
- endometriosis
- adhesions
Ovulation defects (25%)
- excessive exercise
- underweight
- hyperprolactinaemia
- PCOS
- premature ovarian failure
Unexplained infertility (25%)
Uterine factors
female history for infertility
Age Duration of fertility Type of infertility are periods regular? previous ectopics/miscarriages/terminations? excess body hari/acne/weight gain? PCOS dysmenorrhoea/menorrhagia? ENDOMETRIOSIS
Hx of STIs
Tubal surgery/ PID
Pelvic surgery
examination for infertility
BMI Body hair distribution Galactorrhoea Secondary sexual characteristics Pelvic – structural abnormalities fixed or tender uterus
male history for infertility
General health Alcohol/smoking Previous surgery Previous infections Sexual dysfunction – erectile/ ejaculatory
male examination for infertility
Not essential in the absence of any relevant history Scrotum – varicocele Testicular size Testicular position – undescended testes Prostate – chronic infection
female baseline Ix and additional Ix
- Follicular phase LH, FSH and oestradiol early in the follicular phase (Day 2-6)
- Progestrone test - mid-luteal phase (D21)
- measure TSH, prolactin and testosterone if cycle is shortened, irregular, prolonged, progestrone indicates anovulation
- TVUS - fibroids, PCOS
- Rubella status
- Hep B surface antigen, Hep C antibody and HIV 1&2 antibody
- Tests of tubal patency
- Pelvic ultrasound scan (ovaries, uterine abnormalities)
- Hysteroscopy
Testosterone/SHBG
tests for tubal patency
Hysterosalpingography (HSG)
Diagnostic laparoscopy and dye
male baseline Ix for infertility
additional Ix for infertility
semen analysis x2 2-3 days after abstinence repeated 6 weeks if abnormal
- FSH / LH / Testosterone
- Ultrasound – seminal vesicles, prostate
Mx for anovulation
FIRST LINE
- Clomiphene citrate
SECOND LINE
- Gonadotrophins/Pulsatile GNRH
- Dopamine agonists (Hyperprolactinaemia)
- Weight loss/weight gain
Mx for tubal diseases in fertility
surgery
IVF
Mx if male has the issue
- In vitro fertilisation (IVF)
- Intracytoplasmic sperm injection (ICSI)
- Donor insemination
what is endometriosis
Tissue resembling the endometrium lying outside the endometrial cavity
Predominantly found in the pelvis
Responds to cyclical hormonal changes and bleeds at menstruation
what is adenomyosis
Presence of endometrial tissue within the myometrium
Diagnosed by histology after hysterectomy
Considered by some to be a separate entity
aetiology of endometriosis
Retrograde menstruation (Sampson’s theory)
Coelomic metaplasia (Meyer’s theory)
clinical presentation of endometriosis
- Secondary dysmenorrhoea
- Heavy periods
- Dyspareunia
- Lower abdominal pain
- (epistaxes, rectal bleeding, PCB)
- Little correlation between symptom severity and disease severity
clinical examination of endometriosis
NAD Thickened uterosacral ligaments Fixed retroverted uterus Uterine/ovarian enlargement Forniceal tenderness Uterine tenderness
Diagnosis and Ix for endometriosis
Diagnosis made by laparoscopy
Active endometriosis – “powder-burn” spots, chocolate cysts
Inactive endometriosis – “scars”
Peritoneal defects
medical
All hormonal medical therapies suppress ovulation
COCP
Continuous progestogen therapy (MPA)
GnRH analogues (nasal spray/implants) ± HRT “add-back” therapy
(Danazol)
Mefenamic acid/tranexamic acid
surgical Mx of endometriosis
Laparoscopic – diathermy, laser
TAH + BSO
risk of bladder, ureteric, bowel injury
risk of subtotal hysterectomy
role of HRT
when does progestrone level peak
7 days after ovulation has occured
how long is luteal phase
14 days
if progestogen
< 16nmol/l
16-30nmol/l
> 30nmol/l
repeat, if consistently low refer to specialist
repeat
indicates ovulation
key counselling points for couples trying to get pregnant
- folic acid
- aim for BMI 20-25
- advise regular sexual intercourse every 2 to 3 days
- smoking/drinking advice
role of clomifene
antioestrogen
- blocks oestrogen receptors in the hypothalamus + pituitary
- increases the release of LH and FSH
given on days 2 to 6 of each cycle to initiate follicle maturation
limited to 6 months use
Role of gonadotrophin
daily sub cut injection of recombinant or purified urinary FSH and/or LH
stimulates follicular growth
when follicle reached approx 17mm in size - process of ovulation is artificially stimulated by injection of hCH or LH
Sx of pituitary adenoma
galactorrhoea
menorrhagia
bitemporal hemianopia
diplopia
Mx
bromocriptine
