L7 Causes and Treatments of Subfertility Flashcards
What are the requirements for conception? (4)
Progressive motile and normal sperm capable of reaching and fertilising the oocyte
Timely release of a competent oocyte
Free passage for the sperm to reach the oocyte and for the embryo to reach the uterus
A mature endometrium that allows implantation
What is infertility?
Inability to conceive after 2 years of frequent unprotected intercourse
Cumulative probability of pregnancy is 84%, 92% & 93% after 1,2 & 3 years
Reasonable to investigate after 1 year unless there is a concern
Latest NICE guideline definition of infertility
The period of time people have been trying to conceive without success after which formal investigation is justified and possible treatment implemented
If a woman has not conceived after a year, offer further clinical assessment and investigation, along with her partner
Causes of infertility
Unexplained 30% Ovulatory 27% Male factor 19% Tubal 14% Endometriosis 5% Other factors 5% (uterine, endometrial, gamete or embryo defect)
Combined male & female in 39%
Prevalence of infertility
1 in 6 couples have a problem conceiving
Indications for early referral/investigation: FEMALE
Aged over 35 years
Amenorrhoea/oligomenorrhoea
Previous abdominal/pelvic surgery
Previous PID/STD
Abnormal pelvic examination
Indications for early referral/investigation: MALE
Previous genital pathology (history of testicular maldescent, surgery, infection or trauma, there is a greater incidence of abnormal semen parameters)
Previous STD
Significant systemic illness
Abnormal genital examination
Components of semen analysis
Count
Motility
Morphology
Volume
Abnormal semen analysis
No reason in 50%
1 yr testicular failure is the commonest cause for oligo/azoospermia
Obstructive or non-obstructive azoospermia => FSH, LH & T
Y chromosome micro deletion & cystic fibrosis if sperm count < 5 million
Fertility and female age
Single most important factor
A woman’s fertility declines with age
This is due to the decline in oocyte number and quality rather than uterine receptivity
The increased rate of chromosomal abnormalities in the oocyte also results in higher aneuploidy and miscarriage rates
Female assessment
Screen for chlamydia & rubella
Ovarian reserve
- early follicular phase hormone level (FSH, LH, & E2)
- AMH (anti-mullariam hormone)
- AFC (antral follicle count)
Ovulation test
Tubal test
The human ovary & follicular development
Primordial follicles - prophase 1 of meiosis
-oocyte diameter 35u
At 100 days, antral follicles form
Start to mature into maturing follicles
-oocyte diameter 100u
Lastly becomes pre-ovulatory follicle
The the of 99% of all follicles is atresia
1) at primordial - primary transition
2) at antral staged upon FSH deprivation
AMH (anti-mullarian hormone)
Produced by the Granulosa cells of pre-antral and small antral stages
Levels of AMH constant through monthly periods but declines with age
Higher AMH levels predict a good response
Lower AMH levels predict a poor response
Who ovulates?
Most women who have a regular menstrual cycles (26-35 days) will be ovulating
How to test ovulation?
BBT
Ovulation detection kits
Cervical mucous pattern
Follicular tracking or mid-luteal phase P4 (7/7 before menstruation)
Mid-luteal P4 >30nmol/L accepted as evidence of ovulation
?? Leutinised unruptured follicle
Follicular tracking is more reliable but costly & labour intensive