Lecture 14- Infertility Flashcards
subfertility definitition
a couple who are having regular (every 2-3 days), unprotected sex who have failed to conceive within 1 year
types of infertility
primary
secondary
- Primary infertility
- never been pregnancy
- Secondary infertility
- Previous pregnancy
- Ectopic and termination included
Infertility prevalence
- 1 in 7 couples
- 84% couples will conceive naturally within 1 year with regular unprotected sex
- 92% after 2 years and 93% after 3 years
- After 3 year chance if spontaneous preg <25%
Causes
- Unidentifiable – 25%
- Male and female factors -40%
- Male causes- 30%
- Ovulatory causes- 25%
- Tubal factors – 20%
- Uterine and peritoneal disorders- 10%
- others
- gamete, embryo/defects, coital problems, concurrent health problems
male causes can be split up into
pre-testicular
testicular
post testicular
Pre-testicular causes of infertility
-
Endocrine
- hypogonadotropic hypogonadism
- hyperprolactinemia
- hypothyroidism
- diabtes (hard to keep erection)
-
Coital problems
- ejaculatory disorders, erectile dysfunction
- General health/systemic illness
testicular
-
Genetic
- Klinefelter syndrom XXY
- Y chromosome deletion
- Immotile cilia syndrome
-
Congenital
- cyrptochidsm
-
Infective
- STI
-
Antispermatogenic agents
- heat
- irradiation
- drugs
- chemotherapy
-
vascular
- torsion
- varicocele
Post testicular
-
Obstructive
- Congenital - CBAVD/CUAVD
- Acquired- infective, vasectomy
-
Coital problems
- sexual dysfunction
- hypospadias
Hypospadias
is a condition in which the opening of the urethra is on the underside of the penis instead of at the tip
Ovulatory causes
- Group I- hypothalamic pituitary failure- 10%
- Group II- hypothalamic-pituitary-ovarian dysfunction- 85%
- Group III- Ovarian failure- 5%
- Ovulatory cause: Group I- hypothalamic pituitary failure- 10%
- Hypothalamic amenorrhoea
- Hypogonadotropic hypogonadism
- Ovulatory causes- Group II- hypothalamic-pituitary-ovarian dysfunction- 85%
- PCOS
- Hyperprolactinaemic amenorrhoea
ovulatory causes: Group III- Ovarian failure- 5%
- Premature ovarian failure
- Congenital e.g. Turners syndrome (45xO)
Uterine and peritoneal disorders
Physical reasons by implantation fails
- Uterine fibroids
- Conditions causing scarring/ adhesions
- Endometriosis
- PID
- Previous surgery
- Asherman syndrome- scaring within uterus e.g. after procedure
- Mullerian developmental abnormalities
Tubal damage
Conditions affecting fallopian tube- disrupted transport of ovum e.g.
- Endometriosis
- Ectopic pregnancy
- Pelvic surgery
- PID
- Mullerian developmental anomaly- agenesis
questions to ask on presentation
- full medical and surgical history
- social history
- smoking/alcohol/occupation
- previous children/pregnancies
- sexual health history
- sexual dysfunction
specific questions to ask men
- testicular trauma/disorders
- ejaculatory/erectile dysfunction
specific questions to ask females
- age
- obstetric/gynae history
- cycle
- cervical smear
- procedures
- menstrual disorders
male examination
- usually not required
- examine penis for structural abnormalities
- scrotal exam
- secondary sexual characteristics
female examination
- BMI
- secondary sexual characteristics
- hirsutism, acne
- abdominal/ pelvic/ vaginal exam
what are you feeling for in abdominal/ pelvic/ vaginal exam
masses, tenderness, infection, uterus size/position, vaginismus
Vaginismus is the body’s automatic reaction to the fear of some or all types of vaginal penetration. Whenever penetration is attempted, your vaginal muscles tighten up on their own. You have no control over it. Occasionally, you can get vaginismus even if you have previously enjoyed painless penetrative sex.
Advice to patients
- Smoking cessation
- Reduce alcohol
- Lifestyle changes
- Regular intercourse
- Weight loss
- REASSURANCE – limit stress
Investigations
Male
- Semen analysis
- Sperm count, motility, liquification studies
- Bloods- LH, FSH, testosterone
- STI screen
- USS testes (ultrasound)
- karyotyping
Female investigations
- Bloods
- FSH/LH (day 2)
- Mid luteal phase progesterone (day 21-28 of cycle)
- TFTs, prolactin levels, androgens
- STI screen
- Pelvic USS
- Hysterosalpingogram (HSG)
- Diagnostic laparoscopy
hysterosalpingogram (HSG)
an x-ray procedure used to see whether the fallopian tubes are patent (open) and if the inside of the uterus (uterine cavity) is normal.
Referral to secondary care
- Differs locally
- Consider referral if Hx, exam and Ix normal in both partners and not conceived after a year
- Consider early referral in
- Women >36 (after 6 months)
- Known cause/ predisposing factors
- Offer counselling throughout process
Management options (specilialists)
- Medical treatment- ovulation induction e.g. Clomifene
- Surgical treatment – to rx tubal occlusion e.g. laparoscopy
- Assisted reproductive technology (ART) = means of conception other than normal coitus e.g. intrauterine insemination, IVF etc
