Jeff (Fertility/Infertility and conception/contraception) Flashcards
What is fertility, infertility, and virility?
Fertility- for a couple (man and woman) it is the ability to conceive and have children through normal sexual intercourse.
Infertility- defined as the failure to conceive after a year of regular intercourse (every 2-3 days throughout the month) without contraception.
Virility- (in a man) the quality of having strength, energy, and a strong sex drive, masculinity (possession of normal primary sex characteristics e.g. facial hair, deep voice).
(Virility and fertility are closely linked in a male’s mind. Talking about fertility problems can cause them to be defensive about their masculinity).
2 types of infertility
Primary infertility: one who’s never conceived a child in the pat struggling to do so. (More severe infertility)
Secondary infertility: one who’s had 1 or more children/pregnancies in the pas but now having difficulties in doing so again. (Due to things from childbirth e.g. scarring/damage)
What sort of questions would you ask a couple trying to conceive?
How long have they been trying
Age of patient
General history (do they have any children)
Family history (e.g. narrow fallopian tubes)
Any diseases/illnesses (e.g. STIs)
How often do they have sex
Contraception
Current medications
Lifestyle (alcohol, smoking, job, stress, drugs)
What physical examinations can be performed on couples trying to conceive?
Women:
- Weight (BMI)
- Pelvic examination (PID- pelvic inflammatory disease, fibroids, lumps, tenderness)
Men:
- Weight (BMI)
- Penial/testicular examination for any abnormalities (Peyronie’s disease- scar tissue forms in deeper tissued under skin of penis, Phimosis- the inability to retract the skin covering the head of the penis, Paraphimosis- when the foreskin becomes trapped behind the corona of the glans penis, Balanitis- inflammation of the glans penis)
Tests to diagnose infertility
- Sperm test
- Blood tests to check ovulation
- Test for chlamydia
- X-ray of fallopian tubes
- Ultrasound scan
- Laparoscopy
These tests will uncover a cause in around 80% of persistent failure to become pregnant. In the remaining 20% of cases, no clear cause can be found.
Sperm test
1 in 3 cases of infertility problems are due to the male partner. Tests can help identify issues like oligozoospermia (low sperm count), azoospermia (no sperm count) and motility issues.
A sperm count anywhere in the range from 15 million to 150 million per ml is considered normal, as long as the total ejaculate sperm count is over 22 million sperm.
As well as sperm count, the motility and health of the spermatozoa is also very important- any structural differences can make the sperm less effective or ineffective.
Sperm
Boys start producing sperm at puberty.
It takes about 70 days for a sperm to be produced, but production is a continuous process, there is always plenty of fully matured sperms at any one time.
Sperms are minute. Only 1/25mm long and 1/250mm wide.
They are made up of 3 parts- a head (containing sex chromosomes), a middle (which gives them the energy), and a tail (for swimming).
On average men produce around 150-1000 million sperms daily so they are unlikely to run out.
Sperms are excellent swimmers. They can swim through the cervix into the uterus in about 2 minutes given the right conditions.
Sperms are survivors and can live for up to 7 days in a woman’s body.
Sperm production can be damaged by untreated STIs, excess heat, alcohol, smoking, and recreational drugs.
Blood tests to check ovulation
Hormone imbalances can cause ovulation problems, and a blood test can help determine whether this is happening. This can help with the diagnosis of conditions like polycystic ovary syndrome (lots of cysts on one or both ovaries, usually just on one so can cause painful alternative months when ovulating).
Eggs
Unlike men, women are born with all the eggs they’ll ever have.
At zygote stage, they have about 4 million eggs.
At birth this is reduced to around 1 million.
At puberty this is further reduced to around 300,000.
Only 300-400 will be ovulated during a women’s reproductive lifetime.
The quality of eggs reduces as a woman ages and so does fertility.
At age 40 most women only have 3% of eggs left.
Geriatric mothers are ones who are pregnant at/after 46 years old. Risk for Down syndrome and other illnesses increase after this age due to ageing of the eggs and breakdown of them. More chance of a damaged egg being fertilised.
Test for chlamydia
Chlamydia is the most common STI in the UK. It can cause pelvic inflammatory disease and fertility problems.
Both both men and women can be tested.
X-ray of fallopian tubes
This is called a hyterosalpingogram (HSG). Opaque dye is injected through the cervix while women have an x-ray. The dye will help doctors to see if there are any blockages in their Fallopian tubes. Blockages can prevent eggs passing down the tubes to the womb, and so stop pregnancy occurring.
Ultrasound
Trans-vaginal ultrasound scan is a small probe placed in the vagina. This scan can help doctors check the health of ovaries and womb.
Certain conditions that affect the womb such as endometriosis and fibroids, can prevent pregnancy from happening.
Endometriosis- a common condition where tissue that behaves like the lining of the womb is found outside the womb. The endometrium can attach to different organs such as the abdomen and cause pain. It can take 10 years for a woman to be diagnosed with endometriosis.
Laparoscopy
Keyhole surgery where a camera at the end can be inserted into a small cut in the lower abdomen to examine the health of a woman’s womb, Fallopian tubes and ovaries.
dye might be injected into the Fallopian tubes through the cervix to highlight any blockages in them.
Laparoscopy is usually only used if its likelihood of a problem, for example, history of PID, or if a scan suggests a possible blockage of one or both Fallopian tubes.
Treatment options
No single fertility treatment is best for everyone. The right treatment will depend on circumstances, including the cause of fertility problems, the age of the female partner and medical history.
There are 3 main categories for treatment:
1. Fertility medicines
2. Surgical procedures
3. Assisted conception
Fertility medicines
Usually prescribed to women.
e.g.:
- Clomifene- to help ovulation problems
- Tamoxifen- alternative to clomifene (also used for breast cancer)
- Metformin- can be used but it is unlicensed in the UK. It stimulates ovulation which encourages regular monthly periods and lowers the risk of miscarriage. It also lowers high BG levels and reduces the risk of heart disease and helps in the management of PCOS.
- Gonadotropins- used if unsuccessful with Clomid or metformin but high risk of multiple births. Can also be used in men to improve sperm production.
- Dopamine agonist- e.g. bromocriptine and cabergoline.
Surgical procedures
These include Fallopian tube surgery, which can helpful if the Fallopian tubes become blocked or scarred preventing pregnancy.
Men can have surgery too if sperm production is normal but there is a blockage.
A common problem is a varicocele, or varicose vein in the testicles, that interferes with sperm development. Surgery can correct this problem in more than half of cases.
Assisted conception
This can include intrauterine insemination (IUI) in which sperm is placed into the uterus using a fine plastic tube. This can be helpful in cases of mild sperm problems (e.g. sperm blocked from getting out, pelvic injuries, low motility)
Assisted conception also includes IVF (in vitro fertilisation) in which sperm and eggs are mixed outside the body and put back into the womb. This can be helpful in cases of unexplained infertility and more severe sperm problems (blocked tubes).
If eggs and sperm are both fine but womb is faulty the zygote won’t survive. Can use surrogate mother. Can also be used if mother wouldn’t survive the pregnancy. NHS doesn’t directly find surrogate but can help if part of a fertility service.
Egg and sperm donation
Donors can donate eggs or sperm to help people conceive. Treatment with donor eggs is usually carried out using IVF. Treatment with donor sperm can be IVF or IUI.
Donors must provide information about their identity.
This is because a child born as a result of donated eggs or sperm is legally entitled to find out the identity of the donor when they become an adult.
People may need donor eggs/sperm if they are a same sex couple, have damage to ovaries/uterus, abnormality with either egg or sperm that will never be viable
Conception
Conception is when a woman’s egg is fertilised by a man’s sperm, and then implants itself into the woman’s womb.
To conceive a child, a woman must ovulate- release a mature egg from one of her ovaries.
Her male partner must ejaculate tens of millions of mature motile sperm.
A sperm must reach and penetrate the egg as it travels from the ovary to the uterus.
There fertilised egg must then be able to divide many times, implant in the uterus, and form the placenta that is its lifeline until birth.
Complete conception process:
1. Ovulation
2. Into the Fallopian tube
3. There sperm’s journey
4. Sperm penetrates egg
5. Cells start to divide
6. Implantation
7. Pregnancy hormones
8. Foetal development
Menstrual cycle
Women of childbearing age have a period approximately every 24-32 days
It can be irregular in many women and thus an unreliable means of natural contraception.
Zygote, embryo and foetus
Zygote: the very first stage of life and starts after the union of egg and sperm. About 24 hours after the fusion, the first division of the new cell happens, and it is no longer called zygote. The embryonic period begins (fertilised but a single cell)
Embryo: mid way between zygote and foetus. It is the active cell division period of conception. (24hrs -8weeks after fertilization) (once it has divised)
Foetus: from week eight of pregnancy onwards, the embryonic period ends and makes space for the so-called foetal period of pregnancy.
Cytotoxic medicines can cause cell death of embryo. If the embryo is made up of 4 cells and 1 cell dies from the medicine, you lost 25% of the embryo. Need to be careful when handling or using these medicines.
Ovulation
Ovulation test kits detects Luteinising hormone (LH)
Signs of ovulation include;
- Change in cervical fluid: cervical fluid that resembles “egg whites” is a sign that you are near ovulation or are ovulating. (Thin mucus helps sperm swim and becomes thick to aid protection)
-Increase in basal body temperature: prior to ovulation, the basal body temperature is rather consistent. Closer to ovulation, there might be a slight decline, but it will be followed by a sharp increase after ovulation. The increase in temperature is the sign that ovulation has just occurred
- Change in cervical position or firmness: during ovulation, the cervix will be soft, high, open and wet
Pregnancy and Folic acid
Pregnancy test kits detect hCG (Human Chorionic Gonadotropin). Test should be done with the first urination of the day, mid stream.
Folic acid (key vitamin for development of spine) (also known as vitamin B9) is very important for the development of a healthy foetus, as it can significantly reduce the risk of neural tube defects (NTDs), such as Spina bifida (unprotected, exposed spinal cord) and Anencephaly (neural tube high up doesn’t close and baby does not survive for very long).
The Department of Health recommends that women should take a daily supplement of 400 micrograms of folic acid while they are trying to conceive, and should continue taking this dose for the first 12 weeks of pregnancy when the baby’s spine is developing. However, it is safe to continue taking folic acid supplements after 12 weeks (minimal benefits though).
Some women (e.g. obese BMI) have an increased risk of having a pregnancy affected by a neural tube defect and are advised to take a higher dose of 5 milligrams (5mg) of folic acid each day until they are 12 weeks pregnant.
Risk factors for neural tube defects
Woman or her partner have a neural tube defect.
Woman previously had a pregnancy affected by a neural tube defect.
Woman or her partner have a family history of neural tube defects.
Women with diabetes or epilepsy.
