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
Problems with ovulation
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)
Tubal Patency
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
Risk of tubal damage
12% after one episode of pelvic infection,
23% after two episodes, and
54% after three episodes
Investigations for tubal patency
Hysterosalpingogram (HSG)
Hysterosalpingo-contrast-ultrasonography (HyCoSy)
Laparoscopy & dye
If low risk of tubal disease offer HSG or HyCoSy
Chlamydia screening before instrumentation
HSG
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%
HSG v Lap & Dye
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
HyCoSy (Ultrasound & Dye)
Similar to HSG
No radiation Relatively safer
Ovarian and uterine assessment is possible
Time-consuming & requires training
Lap & Dye
Invasive procedure with inherent risks of visceral injury to the patient
Lap & dye is more sensitive & specific
Chance to diagnose & treat endometriosis & adhesions
Uterine abnormality
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
