Investigation to infertility Flashcards
What is NICE definition of infertility?
A couple is referred for clinical assessment for infertility if, after regular (every 2-3 days) sexual intercourse, they have not conceived in a year
What is primary and secondary infertility?
Primary- Couples who have never conceived
Secondary- Couples who have previously conceived
How is fertility affected by age?
Fertility decreases with age
State some risk factors of developing infertility
- Age (spefically in women)
- Obesity, anorexia/excessive exercise
- alcohol, drugs, smoking and occupation exposure
- ovulatory disorders
- tubal damage e.g. infection, blocked fallopian tubes, endometriosis
- low sperm count
- endocrine disturbances
- infertility (1:7)
- 25% of couples have unexplained infertility
Describe effects of obesity on fertility
Fertility decreases as BMI increases. Shown to be true in both males and females
What needs to be investigated in suspected female infertility`?
- assess menstrual cycle
- other hormonal causes of infertility (hypothyroidisms and prolactinaemia)
- assessing ovarian reserve
- structural or other abnormalitites (chlamydia)
How is the menstrual cycle assessed in suspected inferitlities (female)?
- Assess regular cycles occur (26-36 days) - indicative of ovulation
- ovulation: mid-luteal phase progesterone (day 21)(>30nmol/L)
- if there are irregular cycles then day 2-5 LH and FSH to rule out menopause/premature ovarian failure
- Rule out pregnancies using hCG
What causes anovulation/oligovulation?
- Hypothalamic pituitary dysfunction
- hypogonadotrophic hypogonadism
- ovarian failure
Biochemical features of the causes to anovulation/oligovulation?
Hypothalamic pituitary dysfunction
- abnormal gonadotrophins and normal E2 -PCOS
Hypogonadotrophic hypogonadism
- Low FSH, LH, E2, but normal prolactin
Ovarian failure
- High LH, FSH and low E2
Match the following
- Low FSH
- Low LH
- High FSH
- High LH
- Low E2
- High E2
A. Ovarian failure
B. Hypogonadotrophic hypogonadism
C.
A345
B125
C
What are some other hormonal causes of infertility in females? and how is it investigated
Hypothyroidism and prolactinaemia.
- Thyroid disease investigated using a TFT
- subclinical hypothyroidism occur in 0.88-11.3% of women with ovulation disorders, causing menstrual and ovulatory disturbance associated with infertility
- prolactin will be measured when there is ovulation disorder, galactorrhoea, or suspected pituitary tumour/disorder
- hyperprolactinaemia cause irregular menstruation and possible infertility
How is the overian reserved assessed in suspected infertilities?
- antral follicle count <4, by transvaginal ultrasound scan
- Serum AMH <5.4pmol/L
- Day 3 FSH>8.9 IU/L
What is the trend of AFC count in relationship to age adn BMI?
AFC increases with age and significantly increase with BMI
What structural abnormalities can cause infertility in females? what investigation
- Main is chlamydia
- tubal disease cause 14% infertility in women. Tubal obstruction could be due to infection (chlamydia), surgery or endometriosis
- tubal patency is tested by HSG laproscopy with dye
What is polycystic ovarian syndrome?
- most common cause of anovulatory infertility
- associated with hirsutism, other features of metabolic syndrom: hyperinsulinaemia, insulin resitance, dyslipidaemia
- Not all PCOS have polycystic ovarias, not all paitents of ovarian cysts have PCOS
- hyperandrogenaemia
Investigation to PCOS?
- Serum testosterone high >5pmol/l
- SHBG used to calculate free androgen index
Define infertility in males
- low sperm count or quality
- azoospermia = impaired semen quality
What causes azoospermia?
Primary testicular failure
Obstruction of the genital tract
Hypogonadotropic hypogonadism
What is the primary test for infertility in males?
Semen analysis which includes sperm count, motility, volume, pH, viability and WBC.
- If abnormal then repeat in 3 months to confirm
What are some follow up tests in the investigation of male infertility?
Rule out hypogonadotrophic hypogonadism
- FSH to detect primary from secondary testicular failure and investigate azoospermia
- testosterone
- LH
- oestradiol if gynaecomastia present
- prolactin if pituitary disorder suspected
What are some non-biochemical causes of infertility in men?
Chlamydia, drugs/alcohol abuse, infections (raised leucocytes), impotence/anejaculation
Biochemical features of the azoospermia causes.
Hypogonadotrophic hypogonadism
- low FH, FSH, testosterone and failure of spermatogenesis
Primary testicular failure
- high FSH and LH, low testicular volume
Obstruction of genital tract
- normal FSH and normal testis size
What are some causes of Primary testicular failure?
Cryptorchidism, chromosome disorders (kleinfelters), systemic disease, radio/chemotherapy
- But 66% are unknown
How do you treat infertility in females?
First line- medication for lack of ovulation e.g. anti-oestrogen, clomifene.
2nd line: endometrial scarring, fallopian tube repair, laparoscopic ovarian drilling
How does clomifene restore fertility?
Clomifene is a selective oestrogen receptor modulator, which blocks negative feedback of oestrogen on GnRH release. Stimulating ovulation via FSH production to induce follicle development in anovulatory infertility
What is the success rate of clomifene? and drawbacks?
Clomifene has a 70% succession rate in achieving ovulation in anovulatory cycles.
- only used for 6 cycles
- fails more in higher BMI
What is the treatment for infertility in males?
Dependent on cause
- Primary testicular failure = testosterone replacement
- hypogonadotrophic hypogonadism= treat using hCG or pulsatile GnRH therapies
