Infertility + sexual dysfunction Flashcards
Outline the process of conception
- Sperm deposited in vagina - travel - a few reach the fallopian tube and swim to the oocyte (within 30m of ovulation)
- Sperm surround zona pellucida- acrosome reaction to lose plasma membrane - penetrate oocyte
- 2nd meiotic division of ovum occurs, sperm + ovum haploid nuclei combine, 46 chromosomes
- Fertilised egg travels along tube by peristalsis + cilia
- Cleavage of zygote - morula - fluid filled cavity develops - blastocyst
- Embryonic pole of blastocyst attaches to endometrium, cut-trophoblast destroys endometrial cells, endometrial cells become large + pale (decidual reaction)
Define infertility
No conception after 12 months in a couple having regular unprotected coitus (every 2-3 days)
- Primary - no previous pregnancy or live birth
- Secondary - no conception after a previous pregnancy even if it ended in miscarriage/ectopic/TOP
Define subfertility
A delay in conceiving, usually due a problem in one partner that can be compensated for by higher function in the other
RF for infertility
- Female age >35, in males age less relevant but older=more sperm abnormalities
- Serious systemic illness
- Inadequate nutrition
- Excessive exercise
- Stress
What are the causes of infertility?
- Ovulatory - oligo/amenorrhoea. hypogonadotrophic when pituitary hormones fail (e.g. after radiotherapy or Kallman’s syndrome), PCOS, premature ovarian failure (depletion of follicles before age 40), hyperprolactinaemia (e.g. pituitary micro adenomas). 20%
- Tubal factors - block access to uterus. Infections (usually C trachomatis causing pyosalpinx/hydrosalpinx), congenital anomalies (rare), peritubal adhesions (appendicitis, IBD, tho these usually aren’t in the lumen). 15%
- Uterine factors - make implantation more difficult. Submucosal fibroids, Asherman syndrome (adhesions from infection/surgery), endometriosis, congenital like intrauterine septum.
- Cervical factors - hostile mucus (infection, anti-sperm antibodies), dyspareunia
- Male factors - poor quality sperm. 30%
- Unexplained - 25%
How do you assess a couple presenting with fertility problems?
- See together
- Reassurance that 84% conceive in 1y and 93% by 3y, encourage regular intercourse
- History: h/o contraception, length of trying, previous conceptions of either partner (inc past relationships), complications with pregnancies, full gynae hx inc STIs, general PMH, h/o undescended testes or orchidopexy in the man
- Examination: BMI, hirsute features, don’t normally need further exam
- Investigations: considered after 12m
What investigations are indicated for fertility problems?
- Female: mid-luteal phase progesterone (7d before expected period), chlamydia screen
- If indicated may also check FSH+LH, TFTs, prolactin; in secondary care do tubal patency testing using US with contrast, or if h/o PID/endo/prev ectopic do a diagnostic laparoscopy with dye
- Male: semen analysis, at least 2d of abstinence but no more than 7d, take to lab within 1h, needs to be complete. If 1st normal can assume is not a male problem; also Chlamydia screen
General management of infertility
- Folic acid
- Screen for cervical + rubella
- Stress management, counselling
- Smoking cessation, weight loss, alcohol (ideally none but incomplete evidence)
Medical management of infertility
- Clomiphene citrate - induces induction in anovulation by opposing oestrogen, given on day 2-6 of cycle. Well-tolerated but s/e may include PCOS cysts enlarging, tender breasts, cholestatic jaundice or abdo distension
- Gonadotrophins - FSH or FSH+LH. Can give to woman, or to man if has hypogonadotrophic hypogonadism. CI in breast/ovarian/uterus/pituitary tumours, s/e are tender breasts and OHSS and PV discharge/bleeding
- Dopamine agonists: e.g. cabergoline
- Metformin in PCOS to reduce insulin resistance
- Treat endometriosis with COCP, GnRH agonist, medroxyprogesterone - but this suppresses ovarian function
Surgical management of infertility
- Ovarian drilling
* Tubal surgery - resection, adhesiolysis (for endometriosis)
What is assisted conception?
Conception achieved through means other than coitus. Encompasses intrauterine insemination, IVF, ICSI, donor insemination, oocyte donation and embryo donation
Intrauterine insemination
- Sperm put in uterus at the time of ovulation - more chance of reaching FT for fertilisation
- Good for cervical cause as bypasses this
In vitro fertilisation
- Eggs retrieved, mixed with sperm, incubated, embryo injected into uterus
- Good for backed tubes, men with minor sub fertility or unexplained cause
Intracytoplasmic sperm injection
- Inject individual sperm into an egg to bypass natural barriers to fertilisation, then embryo put into uterus
- Useful when there’s a low sperm count or erectile/ejaculatory dysfunction
Donor insemination
- IUI with donor sperm
* E.g. female same sex relationships, men with very few sperm or infectious disease
Oocyte and embryo donation
- Oocyte: stimulate + collect donor egg, fertilised by recipient sperm, transferred to recipient uterus after it has been hormonally prepared. Good for ovarian failure, Turner syndrome, b/l oophorectomy
- Embryo: donation by couples who’ve had successful IVF/ICSI and have embryos left over
What is ovarian hyperstimulation syndrome and why does it happen?
A complication of gonadotrophic drugs, particularly from IVF.
Drugs stimulate ovaries - excessive response - release oestrogens + VEGF - ovaries enlarge - fluid shift into 3rd space - ascites, effusions, oliguria
How does ovarian hyperstimulation syndrome present?
Abdo swelling/pain, vomiting
Extreme thirst, VTE, dehydration, pleural effusion
Can lead to ARDS and renal failure
What is the management for ovarian hyperstimulation syndrome?
Monitor U+E and LFTs
ACEi and indomethacin may help
Eventually the ovary cysts resorb and ovary goes back to normal size
Dyspareunia
- Superficial: pain on entry. Causes include infection in vulva/vagina, narrowed intraoitus (e.g. congenital, excess suturing post-episiotomy), menopausal (atrophic vaginitis, lichen sclerosus), vulvodynia, functional (lack of lubrication as not enough stimulation or emotional cause of this)
- Deep: pain on deep penetration. Causes include PID, retroverted uterus with ovary prolapse into PoD, endometriosis, neoplasia of cervix/vagina, post-op scarring, foreign bodies
- Apareunia: unable to have intercourse e.g. imperforate hymen or congenital vaginal absence
Vaginismus
Muscle spasm (pelvic floor + thigh adductors) causing pain on attempted penetration
- Primary - fear
- Secondary - past experience of pain on intercourse or assault or a difficult delivery or post-surgery
Loss of libido
- Can occur in either sex
- Repression of sexual thoughts, cultural - if always been like this
- New onset: relationship issues, major life events, depression, endocrine problems, pain, menopause, stress, drugs like anti-depressants/cytotoxics/anti-oestrogens/sedatives/narcotics
What is the physiology of male sexual function?
Erection - vasoconstriction via PSNS
Ejaculation + orgasm - vasodilation by SNS (adrenergic)
Pudendal n opens the external sphincter, bulbocavernosus + ischiorectal muscles contract
Erectile dysfunction (impotence)
- Causes: vessel/nerve damage (e.g. DM), neurological (MS, SC injury, prostate injury), hyperprolactinaemia, psychogenic (stress, depression), drugs (anti-hypertensives, diuretics, antidepressants, alcohol)
- M: sildenafil (Viagara-potentiates effect of NO on vascular smooth muscle), injection of prostaglandin E1, counselling/sex therapy
