Infertility - Women Flashcards
When should a couple be referred to a fertility clinic?
Only if they’re been trying unsuccessfully for atleast 12 months or have other problems such as:
- Irregular Periods
- Relevant PMH
- Testicular Problems
- HIV/HEP B
- Serious Anxiety
> 35s can be referred after only 6 months
List some of the major causes for Female Infertility?
- Ovulatory Disorders
- Androgen-secreting Adrenal Tumour
- Prolactinoma
- Fibroids
- Endometriosis
- Tumours
- Tubal Block
- Unexplained
What are the categories of ovulatory disorders?
Group 1 = Hypothalamic-Pituitary failure
Group 2 = Hypothalamic-Pit-Ovarian dysfunction (mainly PCOS)
Group 3 = Ovarian Failure
How would we treat someone with a Group 1 Ovulatory Disorder?
Optimise their BMI
Moderate exercise if very active
Ovulation induction with GnRH or LH
PCOS is the main Group 2 ovulatory disorder, what is it?
Polycystic Ovary Syndrome
How do we diagnose PCOS?
The Rotterdam Criteria. 2 out of 3 is +ve:
- Androgen excess (Ferriman Gallway Score)
- Infrequent Periods (Anovulation)
- US
What signs would you look for to indicate androgen excess?
- Hirsutism
- Acanthosis Nigricans
- Moderately raised testosterone (& test DHEAS for androgen secreting tumours)
Score Androgen excess by a Ferriman Galway Score
How do we treat PCOS?
1) Optimise BMI
2) Ovulation Induction with Clomifene or Gonadotrophins
How does Clomifene work?
Antagonises oestrogen receptors –> no -ve feedback –> More Gonadotrophins –> Ovulation
Use 50-150mg on days 2-6, prime with progesterone if amenorrhoeic
What must we be careful of when using clomifene?
Ovarian Hyperstimulation
Multiple Pregnancy
Hence why we do Follicle Scanning in the 1st cycle and adjust the dose if required
When would we use Gonadotrophins to induce ovulation instead of clomifene?
If clomifene produces no ovulation or they do but they still don’t get pregnant.
Up to 3-6 cycles using FSH injection
How would you spot an androgen-secreting adrenal tumour?
Testosterone will be very elevated (much higher than in PCOS)
DHEAS will be raised. Follow up with an Adrenal CT.
Symptoms include Hirsutism and Acanthosis Nigricans
How would we treat a case of unexplained female infertility?
Don’t do ovulation induction
Just do IVF
What can cause Tubal block?
- Chlamydia
- Tumour
- Ectopic surgery
- Sterilization
- Fibroid
- Endometriosis
What kind of questions would we want to ask a woman when assessing fertility?
- Duration of infertility
- Past Fertility
- Past pregnancies & Complciations
- Past Contraception
- PMH
- Menstrual History
- Sexual History
- Psychological Assessment
What would you assess on a woman’s exam when thinking of infertility?
Weight, height –> BMI
Fat & Hair Distribution (think hirsutism of androgen excesss)
Galactorrhoea (prolactinoma)
Abdo Exam
Pelvic Exam
What baseline tests can be done outside a fertility clinic to assess fertility?
- Rubella immunity?
- Chlamydia?
- TSH?
- Ovulation?
- Semen Analysis
How do we test for ovulation?
IF they have regular periods do a Mid-luteal (day 21) phase progesterone
If not do day 1-5 FSH, LH, PRL, TSH & testosterone
Once at a fertility clinic we can do futher tests for women, what do these include?
Pelvic US looking for Masses, structural abnormalities etc.
Tubal Patency test looking for Tubal Block
Ovulation tests looking for Ovulatory disorders like PCOS
How do we test for tubal block?
Either with a HyCoSo (Hysterosalpingo-contrast-sonography)
Or Laparoscopy
What can we realistically offer an infertile woman?
Depends on the cause:
- Ovulation induction for ovulatory disorders
- Removal of androgen secreting tumours
- IVF
How does IVF work?
Harvest eggs from ovary
Fertilise with sperm in lab
~5days incubation
Implant embryo using transfer catheter
ICSI is another form of IVF, how does it work?
Injection of a single sperm into mature eggs instead of mixing the two in a lab and allowing for normal fertilisation
