Infertility/subfertility Flashcards
How many couples report infertility problems?
1/7
What is the definition of infertility?
Inability of a couple to conceive after 12 months of regular intercourse without use of contraception
What percentage of couples in general population manage to conceive within one year if the women is under 40 and they do not use contraception and have regular intercourse?
80%
80% of couples in general population will conceive within 1 year if:
Woman is aged under 40
They do not use contraception and have regular intercourse
What are the main questions about why couples might not be able to conceive?
Are eggs available?
Is sperm available?
Can they meet?
Can embryo implant?
What is asked about in female history re: fertility?
Duration of infertility Previous contraception Fertility in previous relationships Previous pregnancies and complications Menstrual history Medical and surgical history Sexual history Previous investigations Psychological assessment
What is check in a female examination re: fetility?
Weight/height BMI Fat and hair distribution Galactorrhoea Abdo exam Pelvic exam
What can a cause of hirsutism be?
PCOS (excessive androgen levels)
What is the clinical scoring system for measuring hirsutism in women?
Ferriman Gallwey Score
What biochemicals are measured to check for hirsutism?
Testosterone
Dehydroeplandrosterone sulphate (DHEAS)
Progesterone
What is acanthosis nigricans a sign of?
Androgen excess
What are you looking for in a pelvic examination?
Masses Pelvic distortion Tenderness Vaginal septum Cervical abnormalities Fibroids
What are the 3 types of fibroid?
Submucous
Intramural
Subserosal
What are the signs of fibroids?
Pressure symptoms
Period problems
Infertility
What are baseline investigations in a female for infertility?
Rubella.immunity
Chlamydia
TSH
Mid luteal progesterone (if periods regular)
Day 1-5 FSH, LH, PRL, TSH, testosterone (periods irregular)
What is the baseline investigation in a male for infertility?
Semen analysis
What are investigations that can be done at fertility clinic?
Pelvic USS Physical exam Testing for ovulation Semen analysis repeat Tubal patency test
How can ovulation be assessed?
Regular monthly menstrual cycles - likely ovulating
Serum progesterone blood test in mid-luteal phase of cycle (day 21) to confirm ovulation
Irregular monthly menstrual cycles - same test later
Blood test to measure serum gonadotrophins (FSH and LH)
What is the screening for tubal occlusion in investigating infertility?
Hysterosalpingography (HSG)
What is a more invasive test to check for tubal occlusion in suspected infertility?
Laparoscopy
What is asked about in male history re: fertility?
Developmental: testicular descent, change of shaving frequency, loss of body hair
Infections: mumps, STIs
Surgical: varicocele repair, vasectomy
Previous fertility
Drugs/environmental: smoking, alcohol, anabolic steroids, chemo, radiation, drugs
Sexual history: libido, frequency of intercourse, previous fetility assessment
Chronic mental illness
What is examined in males re: infertility?
Weight/height
BMI
Fat and hair distribution (hypoandrogenism)
Abdo and inguinal exam
Genital exam: epididymis, testes, gas deferens, varicocele
What can cause epididymitis?
STIs:
- Chlamydia trachomatis
- Gonorrhoea
What is a varicocele?
Dilatation of pampiniform plexus of the spermic veins in the scrotum
What are signs of varicocele and presumptive infertility?
Low sperm concentration and abnormal
What is one of the most common causes of primary hypogonadism with impaired spermatogenesis and testosterone deficiency?
Klinefelter syndrome
What is CBAVD?
Congenital bilateral absence of the vas deferens
What can cause CBAVD?
Cystic fibrosis mutations
When would you refer a couple to infertility clinic?
1 year of trying Period irregularities PMH Testicular problems Abnormal tests HIV/Hep B Anxiety Age: - <35 after 1yr - 35-45 after 6mo - >45 (little can be offered)
What are the 3 classes of ovulatory disorder?
Group I: hypothalamic pituitary failure
Group II: hypothalamic-pituitary-ovarian dysfunction
Group III: ovarian failure
What is included in Group I hypothalamic pituitary failure?
Hypothalamic amenorrhoea
Hypogonadotrophic hypogonadism
How can women in Group I ovulatory disorders improve their chances of regular ovulation, conception and uncomplicated pregnancy?
Increasing their body weight if BMI less than 19
Moderating exercise levels
What can you offer women with Group I ovulation disorders to induce ovulation?
Gonadotrophin-releasing hormone
Gonadotrophins with LH activity
What are signs/signs of PCOS?
Androgen excess
Infrequent periods
Polycystic ovaries
How can you tell there is androgen excess?
Clinical: hirsutism
Biochemical: testosterone levels
What is the management of ovulatory disorders?
Treat underlying cause
Weight loss/gain
Ovulation induction: clomifene or gonadotrophins
What drugs can be used to induce ovulation?
Clomifene
Gonadotrophins
GnRH
What is the action of clomifene?
Binds to estrogen receptors - stimulates gonadotrophin release
And
Direct effect on ovaries
How is clomifene use monitored?
Follicle scanning in 1st cycle
May need dose adjustment
What are side effects of clomifene?
Vasomotor
Visual
When are gonadotrophins used for ovulation?
No ovulation with clomifene
Ovulation but no pregnancy
How are gonadotrophins given to induce ovulation?
FSH by injection
What are hydrosalpinges?
The fallopian tube is blocked and fills with serous or clear fluid near the ovary
What should women with hydrosalpinges be offered before IVF?
Salpingectomy
What are options for male infertility/subfertility?
IVF
Intra-uterine insemination
Surgery: reversal vasectomy/surgical sperm retrieval
Donor insemination
What are the two types of azoospermia?
Testicular
Posr-testicular
What are testicular causes of azoospermia?
Normagonadotrophic
Hypogonadism
Hypergonadotrophic
What are post-testicular causes of azoospermia?
Iatrogenic
Congenital
Infective
What are investigations for azoospermia?
History and exam
FSH, LH, testosterone, karyotype, PRL
CF screen
When should you not offer ovarian stimulation agents (clomifene)?
Women with unexplained infertility
How long should women with unexplained infertility try to conceive before offering IVF treatment?
2 years
What is ICSI?
Intracytoplasmic sperm injection (ICSI)
Injection of mature eggs with single sperm
Incubation overnight
Embryo transferred to uterine cavity
24yr woman present with 18mo history of amenorrhoea since stopping OCP 28mo ago to try for pregnancy. BMI is 31. What is the most appropriate next step investigation?
Hormone profile to check SHBG, free testosterone and FSH and LH and prolactin
24yr woman present with 18mo history of amenorrhoea since stopping OCP 28mo ago to try for pregnancy. BMI is 31. What is the most likely diagnosis?
- Anorexia nervosa
- Hyperprolactinaemia
- Hypogonadotrophic hypogonadism
- PCOS
- Premature ovarian failure
PCOS
Which of the following is correct with regards to PCOS?
- A high FSH and LH level
- Affected women are very fertiile
- Affects >50% infertile pop
- Metformin contraindicated
- US appearance of large number of follicles arranged peripherally in the ovarian cortex of large volume ovaries
US appearance of large number of follicles arranged peripherally in the ovarian cortex of large volume ovaries
28yr woman with PCOS and primary subfertility of 4yra attends fertility clinic. Her cycles are irregular and she is currently on Metformin, helping her weight control (BMI 28), she is amenorrheic. Keen to start fertility treatment. A hysterosalpingogram confirmed bilaterally patent tubes.
What is most appropriate initial mangemt of her subfertilit?
- Advice on weight loss and review 6mo
- Intrauterine insemination for six cycles
- Laparoscopic diathermy to ovaries
- Ovulation induction with clomifene 50mg for 6mo
- Recommend one cycle IVF treatment
Ovulation induction with clomifene
