Lecture 7: Infertility Flashcards
Infertility is defined as?
The failure to concieve after 12 months of unprotected intercourse
Assessement of Male fertility?
Lower reference limits:
count - 15M/mL
motility - 40% progressive
volume - 1.5mL
total sperm # - 39M/ejac
morphology - 4% normal or more (high number of abnormal)
Female assessement?
- Ovulation
- regularity of periods
- E2 at day 12, P4 at day 21
- FSH day 2-4
- AMH
- Timing of intercourse
- STI
Anovulation?
Often caused due to weight issues
Treatment:
- Weight gain/loss to reach acceptable BMI
- GnRH
- Clomiphene citrate (selective estrogen receptor modulator - tricks brain into thinking estrogen is low and this more FSH is needed) - produces many follicles to develop/ovulate
- Letrazole (aromatase inhibitor and is better as causes just one follicle to be released.)
- FSH
PCOS?
Polycystic Ovarian Syndrome
- 10% of women with no ovulation but just continual development of many follicles
- Infrequent or no preiods
- metabolic syndrome - can be caused by being overweight
- Increased androgens
Treatment:
- Weight loss
- Metformin - insulin sensitize
- IVF
Tubal disease?
Mostly tubal pregnancy, a cyst or most commonly adhesions
Treatment:
- surgery to fix tubes
- IVF
Cervical problems?
Endometriosis?
Premature meopause?
IUI - intrauterine insemination is used and is commonly also the first line treatment for unexplained infertility
Endometriosis effects 10% of women and hormonal contraceptives, ablation and IVF are used as >30% are infertile.
Premature menopause or rising FSH and decreasing AMH with age require donor egg and IVF
Surrogacy is the only option if there is no uterus at all. (v rare)
6 Steps of IVF?
- Egg production stimulated by hormone therapy
- Collect eggs via aspiration to get eggs
- Wash up sperm
- eggs and sperm combined at body temp
- culture embryos for up to 5 days
- put back in best embryo and freeze any other viable ones
Ovarian stimulation
- FSH to simulate follicles
- GnRH antagonist to control/prevent ovulation
- GnRH or HCG trigger
- Leuteal support with progesterone to overcome the negative effect on the endometrium by the other drugs
IVF cycle tracking to time trigger? Success rate?
Transvaginal ultrasound
Blood tests:
- Estrogen - 1000 units/follicle
- progesterone < 6pMol/L
The cumulitive success rate between, current cycles, and those frozen (including freeze only cycles done more regularly these days) is about 50% in <35 year olds but decreases with age.
Time lapse photography now helps provide better care
Male infertility problems and treatment?
- Oligospermia - ICSI (intra-cytoplasmic sperm injection) + donor sperm
- OATS (oligoasthenoteratospermia) = low count, slow motility, abnormal morphology - ICSI or donor sperm
- Azoospermia - can be from Kallman’s syndrome (no GnRH), no spermatogenesis, obstruction/vasectomy, CAVD (congenital absence of Vas Deferens) = Donor sperm, Donor insemination, TESA/TESE (testicular sperm aspiration/exctraction + ICSI)
Unexplained infertility likely causes?
- Unknown aetiology
- Fertilisation issue
- Age
Treatment:
- Mild ovarian stimulation with IUI
- IVF ($$$$)
AMH testing?
Allows us to put people into categories for their age. Can be done at any stage of the month and is also used for determining how much FSH is needed for IVF prep.
Is a predictor for IVF but not for natural pregnancy
