Infertility/fertility Flashcards
Primary vs secondary infertility
Primary - couple never been able to conceive
Secondary - couple cannot get pregnant again, previously could w/o difficulty
What are the general causes of intertility?
- Male infertility - 30%
- Ovulatory disorders - 25%
- Tubal damage - 20%
- Uterine or peritoneal disorders - 10%
- No identifiable cause
What is general advice to couples trying to conceive?
- Sexual intercourse every 2-3 days throughout womens cycle
- Prep for pregnanct eg. preconceptual folic acid
- Smoking cessation for both parties
- Avoid drinking excessive alcohol
- Women aim for BMI 19-25
What factors affect natural fertility?
- Increasing age
- Obesity
- Smoking
- Tight fitting underwear - maes
- Excessive alcohol consumption
- Ilicit drug use
What are some ovulation/endocrine disorders causing infertility?
- PCOS
- Pit tumour
- Sheehan’s syndrome
- Hyperprolactinaemia
- Cushing’s
- Premature ovarian failure
What are some of the tubal and uterine abnormalities causing infertility?
Tubal - congenital anatomical abnormalities and adhesions following PID
Uterine - bicornate uterus, fibroids, adhesions of the uterus
What are the ix into infertility carried out in primary care?
- BMI, low = anovulation, high = PCOS
- Chlamydia screen
- Semen analysis
- Female hormonal testing
- Rubella immunity
What is involved in female hormonal testings?
- Serum LH and FSH day 2 to 5 of cycle
- Serum progesterone on day 21 or 7 days before end
- Anti Mullerian hormone
- TFTs
- Prolactin when sx of amenorrheoa and galactorrhea
How are female hormonal tests interpretted?
- High FSH = poor ovarian reserve, pit gland producing extra FSH to attempt to stim follicular development
- High LH = PCOS
- Rise of progesterone on day 21 = ovulation occurred and corpus luteum formed and secreting progesterone
- Anti Mullerian hormone - marker of ovarian reserve, high = good
What ix into infertility are carried out in secondary care?
- US pelvis, look for polycystic ovaries or structural abnormalities of uterus
- Hysterosalpingogram
- Laparoscopy and dye - patency of fallopian tubes, adhesions, endometriosis
What is a hysterosalpingogram?
Scan to assess shape of the uterus and patency of the fallopian tubes.
Tubal cannulation under XR guidance can be performed during the scan to open tubes = increase rate of conception.
Contrast into uterine cavity and fallopian tubes. Risk of infection - prophylactic abx and screen for STI.
What is the management of anovulation?
- Weight loss if overweight pt w PCOS
- Clomifene and letrozole stim ovulation
- Gonadotropins stim ovulation if resistant to clomifene
- Ovarian drilling (punctures holes in ovaries using diamthermy or laser = improve hormones = ovulation)
- Metformin
What is clomifene?
Anti oestrogen - selective oestrogen receptor modulator. Give on day 2 to 6. Stops neg feedback of oestrogen on hypothalamus = increase GnRH = increase FSH and LH.
What is the management of tubal factors that cause infertility?
- Tubal cannulation during hysterosalpingogram
- Laparoscopy to remove adhesions or endometriosis
- IVF
What is the advice for men providing a semen sample?
- Abstain from ejaculation for at least 3 days
- Avoid hot baths, sauna and tight underwear
- Attempt to catch the full sample
- Deliver the sample to the lab w/i 1 hour of ejaculation
- Keep the sample warm
What are some abnormal sperm results?
Polyspermia - high number of sperm in semen sample = >250 million/ml
Oligospermia - reduced number, mild = 10-15 mil/ml, mod = 5-10mil/ml, severe = <5mil/ml
Cryptozoospermia - <1mil sperm/ml
Azoospermia - no sperm in the semen
What are normal sperm results?
Normospermia:
- >1.5ml of semen
- pH >7.2
- Conc >15mil/ml
- Total number = >39 mil per sample
- >40% mobile and >58% active
What are some pre testicular causes of infertility?
Hypogonadotrophic hypogonadism = reduced testosterone which is necessary for sperm:
- Pathology of pit gland or hypothalamus
- Suppression due to stress, chronic conditions or hyperprolactinaemia
- Kallman syndrome - delayed or absent puberty and impaired sense of smell
What are the testicular causes of infertility?
Acquired damage - mumps, trauma, RT and chemo, cancer, cryptochidism
Genetic or congenital disorders - Klinefelter syndrome, Y chromosome deletions, Sertoli cell only sydrome, anorchia
What are some post testicular causes of infertility?
- Ejaculatory duct obstruction
- Retrograde ejaculation
- Scarring from epididymitis eg. chlamydia
- Absence of vas deferens
- Damage - trauma, surgery, cancer
How do you investigate abnormal semen analysis?
- Hormonal analysis w LH, FSH and testosterone
- Genetic testing
- Further imaging eg. transrectal US or MRI
- Vasography - inject contrast into vas deferens
- Testicular biopsy
What is the management of male factor infertility?
- Surgical sperm retrieval if obstruction
- Surgical correction of obstruction
- Intra uterine insemination
- Intracytoplasmic sperm injection - sperm directly into cytoplasm of egg
- Donor insemination
What is involved during one cycle of IVF?
- Suppress natural menstrual cycle
- Ovarian stim
- Oocyte collection
- Insemination/intracytoplasmic sperm injection
- Embryo culture and then transfer
How is the natural menstrual cycle suppressed?
- GnRH agonist protocol - injection during luteal phase, 7 days before expected onset of period, stim pit gland to secrete FSH and LH, negative feedback on hypothalamus due to surge = reduction in natural GnRH = suppress menstrual cycle
- GnRH antagonist protocol - daily SC injectoin eg. cetrorelix, from day 5-6 of ovarian stim. Suppresses LH so no ovulation.
(want follicles to be made but not released as want to collect them)
How is ovarian stim carried out?
Meds to develop multiple follicles in ovaries -SC FSH at day 2 for ~2 weeks. Transvaginal USS to monitor follicles.
When enough follicles have developed FSH stopped and hCG injection 36 hours before egg collection = stim final maturation of follicle ready for collection.
What is involved in oocyte collection and insemination?
Oocytes collected under US guidance, aspirate fluid from each follicle = mature oocytes in it. Check fluid to see if have any oocytes. Male produces a semen sample or frozen samples can be made - sperm and egg mix and egg is hopefully fertilised.
May need to do ICSI in male factor infertility if reduced no or quality of sperm, isolate highest quality sperm and directly inject into egg.
What is involved in embryo culture and transfer?
Fertilised eggs incubated for 2-5 days to see if any develop or grow, monitored until they reach blastocyst stage.
Highest quality embryos are selected for transfer. Catheter through cervix into uterus, single embryo transferred. Remaining embryos frozen.
What is ovarian hyperstim syndrome?
Complication of ovarian stim in IVF treatment - associated w hCG use to mature follicles.
What are the features of OHSS?
- Early presents w/i 7 days of hCG injection, late is >10 days after
- Abdo pain and bloating, N+V
- Diarrhoea
- Hypotension and hypovolaemia
- Ascites
- Pleural effusions
- Renal failure
- Peritonitis from rupturing follicles releasing blood
- Prothrombotic state - risk VTE
What is the management of OHSS?
- Oral fluids
- Monitor urine output
- LMWH - prevent VTE
- Paracentesis to remove ascitic fluid if needed
- IV colloids
