Lecture 14- Infertility

Question 1

subfertility definitition

Answer 1

a couple who are having regular (every 2-3 days), unprotected sex who have failed to conceive within 1 year

Question 2

types of infertility

Answer 2

primary

secondary

Question 3

• Primary infertility

Answer 3

• never been pregnancy

Question 4

• Secondary infertility

Answer 4

• Previous pregnancy
  
  • Ectopic and termination included

Question 5

Infertility prevalence

Answer 5

• 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%

Question 6

Causes

Answer 6

• 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

Question 7

male causes can be split up into

Answer 7

pre-testicular

testicular

post testicular

Question 8

Pre-testicular causes of infertility

Answer 8

• Endocrine
  
  • hypogonadotropic hypogonadism
  • hyperprolactinemia
  • hypothyroidism
  • diabtes (hard to keep erection)
• Coital problems
  
  • ejaculatory disorders, erectile dysfunction
• General health/systemic illness

Question 9

testicular

Answer 9

• Genetic
  
  • ​Klinefelter syndrom XXY
  • Y chromosome deletion
  • Immotile cilia syndrome
• Congenital
  
  • ​cyrptochidsm
• Infective
  
  • ​STI
• Antispermatogenic agents
  
  • ​heat
  • irradiation
  • drugs
  • chemotherapy
• vascular
  
  • ​torsion
  • varicocele

Question 10

Post testicular

Answer 10

• Obstructive
  
  • ​Congenital - CBAVD/CUAVD
  • Acquired- infective, vasectomy
• Coital problems
  
  • ​sexual dysfunction
  • hypospadias

Question 11

Hypospadias

Answer 11

is a condition in which the opening of the urethra is on the underside of the penis instead of at the tip

Question 12

Ovulatory causes

Answer 12

• Group I- hypothalamic pituitary failure- 10%
• Group II- hypothalamic-pituitary-ovarian dysfunction- 85%
• Group III- Ovarian failure- 5%​

Question 13

• Ovulatory cause: Group I- hypothalamic pituitary failure- 10%

Answer 13

• Hypothalamic amenorrhoea
• Hypogonadotropic hypogonadism

Question 14

• Ovulatory causes- Group II- hypothalamic-pituitary-ovarian dysfunction- 85%

Answer 14

• PCOS
• Hyperprolactinaemic amenorrhoea

Question 15

ovulatory causes: Group III- Ovarian failure- 5%

Answer 15

• Premature ovarian failure
• Congenital e.g. Turners syndrome (45xO)

Question 16

Uterine and peritoneal disorders

Answer 16

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

Question 17

Tubal damage

Answer 17

Conditions affecting fallopian tube- disrupted transport of ovum e.g.

• Endometriosis
• Ectopic pregnancy
• Pelvic surgery
• PID
• Mullerian developmental anomaly- agenesis

Question 18

questions to ask on presentation

Answer 18

• full medical and surgical history
• social history
  
  • smoking/alcohol/occupation
• previous children/pregnancies
• sexual health history
• sexual dysfunction

Question 19

specific questions to ask men

Answer 19

• testicular trauma/disorders
• ejaculatory/erectile dysfunction

Question 20

specific questions to ask females

Answer 20

• age
• obstetric/gynae history
  
  • cycle
  • cervical smear
  • procedures
• menstrual disorders

Question 21

male examination

Answer 21

• usually not required
• examine penis for structural abnormalities
• scrotal exam
• secondary sexual characteristics

Question 22

female examination

Answer 22

• BMI
• secondary sexual characteristics
• hirsutism, acne
• abdominal/ pelvic/ vaginal exam

Question 23

what are you feeling for in abdominal/ pelvic/ vaginal exam

Answer 23

masses, tenderness, infection, uterus size/position, vaginismus

Answer 24

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.

Question 25

Advice to patients

Answer 25

• Smoking cessation
• Reduce alcohol
• Lifestyle changes
• Regular intercourse
• Weight loss
• REASSURANCE – limit stress

Question 26

Investigations

Male

Answer 26

• Semen analysis
  
  • Sperm count, motility, liquification studies
• Bloods- LH, FSH, testosterone
• STI screen
• USS testes (ultrasound)
• karyotyping

Question 27

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

Question 28

hysterosalpingogram (HSG)

Answer 28

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.

Question 29

Referral to secondary care

Answer 29

• 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

Question 30

Management options (specilialists)

Answer 30

• 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