L7 Causes and Treatments of Subfertility Flashcards

1
Q

What are the requirements for conception? (4)

A

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

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2
Q

What is infertility?

A

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

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3
Q

Latest NICE guideline definition of infertility

A

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

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4
Q

Causes of infertility

A
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%

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5
Q

Prevalence of infertility

A

1 in 6 couples have a problem conceiving

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6
Q

Indications for early referral/investigation: FEMALE

A

Aged over 35 years

Amenorrhoea/oligomenorrhoea

Previous abdominal/pelvic surgery

Previous PID/STD

Abnormal pelvic examination

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7
Q

Indications for early referral/investigation: MALE

A

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

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8
Q

Components of semen analysis

A

Count

Motility

Morphology

Volume

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9
Q

Abnormal semen analysis

A

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

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10
Q

Fertility and female age

A

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

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11
Q

Female assessment

A

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

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12
Q

The human ovary & follicular development

A

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

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13
Q

AMH (anti-mullarian hormone)

A

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

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14
Q

Who ovulates?

A

Most women who have a regular menstrual cycles (26-35 days) will be ovulating

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15
Q

How to test ovulation?

A

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

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16
Q

Problems with ovulation

A

PCOS commonest cause of anovulation and 1ry or 2ry oligo/amenorrhea

If oligo/amenorrhea FSH/LH, E2, prolactin, TFT, androgens & SHBG

85% PCO (normal FSH/LH & E2)

5%  POF (high FSH & low E2)

10%  hypogonadotrophic hypogonadism (low FSH & low E2)

17
Q

Tubal Patency

A

Disease can be proximal (25%) or distal (75%)

PID secondary to chlamydia is the commonest cause of tubal damage

Other causes: septic abortion, ruptured appendix, pelvic surgery and ectopic pregnancy

18
Q

Risk of tubal damage

A

12% after one episode of pelvic infection,

23% after two episodes, and

54% after three episodes

19
Q

Investigations for tubal patency

A

Hysterosalpingogram (HSG)

Hysterosalpingo-contrast-ultrasonography (HyCoSy)

Laparoscopy & dye

If low risk of tubal disease offer HSG or HyCoSy

Chlamydia screening before instrumentation

20
Q

HSG

A

Done 2-5 days after menstruation

Antibiotics should be given to prevent flare-up of infection if H/O PID

The overall risk of infection is approx 1%

In high risk population this can rise to 3%

21
Q

HSG v Lap & Dye

A

HSG Advantages:

  • relative safety
  • ease of use
  • delineation of the uterine cavity and Fallopian tubes

HSG Disadvatages:
-Inability to assess the pelvic peritoneum

Ideal screening test for the majority of the patients

22
Q

HyCoSy (Ultrasound & Dye)

A

Similar to HSG

No radiation Relatively safer

Ovarian and uterine assessment is possible

Time-consuming & requires training

23
Q

Lap & Dye

A

Invasive procedure with inherent risks of visceral injury to the patient

Lap & dye is more sensitive & specific

Chance to diagnose & treat endometriosis & adhesions

24
Q

Uterine abnormality

A

Adhesions, polyps, submucous fibroids and septae, are estimated to be a factor in 10–15% of couples seeking treatment

HSG, TVS & hysteroscopy

Hysteroscopy is undoubtedly better than HSG & TVS at detecting these abnormalities

25
Q

Ovulation Induction

A

Clomid (Clomifene citrate) for women who have PCO

Anti-oestrogen effect on hypothalamic pituitary axis

FSH injections for resistant PCO or hypogonadotrophic hypogonadism

Risk of multiple pregnancy

Monitor 1st cycle using USS

26
Q

IUI (Intrauterine insemination) treatment usual indications

A

Unexplained

Mild male factor

Mild endometriosis

27
Q

IUI treatment

A

Less stress

Less invasive

Less tech

Cheap

Success rate - 10% per cycle

28
Q

NICE guidelines on IUI treatment

A

Do not offer IUI for couples who have unexplained infertility

IUI for single women, same sex couple or heterosexual couple who have problem with intercourse

IVF for couples who have unexplained infertility

29
Q

IVF for people with?

A

Tubal damage

Low sperm quality

Unexplained infertility

Low ovarian reserve

30
Q

IVF live birth rate

A

Depends on female partner’s age

Varies from one unit to another

National average 30-35% < 35 year old