Management of infertility 2 Flashcards
1
Q
Define infertility?
A
- the term indicates that the ability to become pregnant maybe diminished or absent
- 1 in 6 couples have trouble conceiving
- 50% of these require medical assistance
2
Q
What is primary infertility?
A
- a failure to achieve a pregnancy after 12months of regular, unprotected sex (2-3x per week)
- 85% couples are likely to conceive in 12 months
- 95% likely to conceive in 24 months
3
Q
What is secondary infertility?
A
- failure to achieve a second pregnancy after a couple has already had a pregnancy or child
4
Q
What are some causes of female infertility?
A
- ovulation disorders; decresed ability to release a viable egg for fertilisation, can be due to hormone deficiency
- ovary damage
- infrequent periods (oligomenorrhoea)
- absence of periods (amenorrhoea)
- blocked/ damaged fallopian tubes
- blocked tubes-HSG hysterosalpinigram
- damage due to pervious surgery- scar tissue deposits
- limited egg flow & sperm access
- pelvic inflammatory disease (PID) due to STIs- chlamydia & gonorrhoea
- endometriosis
- uterine tissue grows outside of uterus & can affect ovaries, fallopian tubes,bowel, bladder & rectum
- can effect fertile sperm
- development of scar tissue in the uterus that can impair embryo attachment
5
Q
What are the 3 other causes of female infertility?
A
- fibroids
- non cancerous growth of muscle in the uterus that may affect fertility/ implantation
- PCOS
- ovaries are enlarged & have a thicker outer layer covered by small cysts- can be harmless but affect period regularity and result infertility
- cervical problems
- cervical secretions
- production, consistency & resistance
- cervical mucus assist adequate flow of sperm into the uterus, allow the flow of sperm to enter the uterus & find egg for fertilisation
- cervical secretions
6
Q
WHat are some causes of male infertility?
A
- damage to sperm production- oloigospermia
- obstruction to vas deferens
- testosterone production
- sperm genetics
- sperm abnormalities/ mobility problems
- damage due to cancer therapy
7
Q
Is there such thing as unexplained infertility?
A
- yes
- affects 15% couples
- no diagnostic results to identify a cause
- difficult to manage as targeted therapy can be difficult to achieve
8
Q
What are some liftsyle factors that can affect infertility?
A
- smoking
- women- up risk of ovulation issues & infertility
- men- affect development, quality and volume of sperm
- alcohol
- excessive alcohol intake can be be damaging to general health
- australian standard alcohol rules apply to men
- recommended that women restrict alcohol use when trying to conceive
- recreational drugs
- Cocaine, methamphetamine and marijuana can affect menstrual cycle and ovulation processes
- Sperm count is affected by marijuana intake
- all should be avoided
- caffeine
- Reduction of caffeine intake
- Mixed studies –1-2 standards cups of coffee is recommended / others suggest no caffeine
- weight management
- both male and female fertility can be affected by being overweight or underweight
- balanced diet
- Ensure a well balanced diet is maintained
9
Q
What is the impact of age in fertility?
A
- female fertility is known to decrease with age
- women are most fertile between the ages of 15-25yrs
- from 35yrs of age fertility decreases, the quantity & quality of viable eggs will begin to decrease
- by 50/60 years of age, the total # of eggs available will have usually depleted
- male fertility can persist into old age- some evidence to suggest a reduction of sperm quantity and quality at 45 years of age
10
Q
What are the stages of fertility treatment?
A
- lifestyle modifications
- fertility tracking
- ovulation induction (hormonal therapy)
- assisted reproductive technology (ART)
- artificial insemination & intrauterine insemination
- in vitro fertilisation (IVF)
- IVF with intra-cytoplasmic sperm injection (ICSI)
11
Q
WHat does fertility tracking involve?
A
- cycle tracking
- Also known as the calendar method
- Calculating possible ovulation day based on menstrual cycle
- Ovulation expected to be 14 days before your menstrual bleed
- Timed intercourse to increase likelihood of becoming pregnant 3 days prior to and day of ovulation
- basal body temperature
- following ovulation- temp is expected to rise significantly due to the increase in progesterone levels
- monitor daily temp throughtout the cycle & record days where body temperature has risen
- changes in cervical mucus
- Early in the cycle , cervical mucus is sparse, cloudy and dense
- Ovulation results increased clear fluid to allow for sperm to easily pass
- Monitoring mucus consistency and amount during tracking
- ovulation kits
- Ovulation predictor kits available from pharmacies
- 2 types: urine & saliva test
- Urine Test – detects amount of leutinising hormone in the urine. LH surge will occur 24- 36 hours prior to the release of a mature egg
- Saliva Test – saliva appearance demonstrates a distinctive ‘fern=like’ pattern when oestrogen levels rise before ovulation
- NB: these kits may work for some women although women with PCOS or ovarian failure cannot use them
12
Q
What is ovulation induction?
A
- utilises oral or IV medicines to stimulate the ovaries to produce the follicles that will mature into a viable egg that can be fertilised
- used for an- ovulation (woman who is not ovulating) or decreased luteal phase support
- methods include:
- COC
- metformin in PCOS
- clomiphene
- letrozole
- GnRH agonists
- GnRH antagonists
13
Q
Which COCs are used for infertlity?
A
- low dose COCs used to assist with menstrual cycle regulation & allow for adequate tracking during a fertility cycle
- its used at the beginning of the cycle
- Medroxyprogesterone
- synthetic progesterone
- used in amenorrhoea to cause a uterine bleed
- suppress the LH surge and induce a withdrawal bleed due to increased progesterone indicating low oestrogen levels in the body
- 10mg daily for 12 days
14
Q
How is metformin used in infertility?
A
- metformin in PCOS
- Used to treat anovulatory infertility in women with PCOS
- Insulin resistance is noted as a common feature among patients with PCOS
- In PCOS , insulin resistance is thought to lead to hyperandrogenaemia - hirsutism, acne, infertility
- Metformin reduces hepatic glucose production & increases cellular uptake of glucose
- Reduction in insulin resistance and positive effect on fertility
- IR 500mg bd or tds
- Limited evidence for XR formulations but can be used if GI symptoms not tolerated
15
Q
WHat about clomiphene?
A
- encourage body to release an egg, induce ovulation
- oestrogen receptor antagonist
- it binds to oestrogen receptors at the hypothalamus, hypothalamus detects a decrease in oestrogen levels
- hypothalamus releases GnRH
- GnRH stimulates pituitary gland to release FSH & LH
- FSH & LH cause development and release of follicles & release of follicles and mature egg
- Dose : 50mg daily on day 2 to 5 of cycle
- can be adjusted according to response per cycle up to 150mg
- Maximum of 6 cycles recommended
- 25mg may be used in lower body weight
16
Q
What about letrozole?
A
- aromatase inhibitor?
- increases oestrogen in body
- Aromatase enzymes use circulating androgens and convert them to oestrogen hormones
- Letrozole inhibits aromatase enzymes causing a reduction in production of oestrogen
- Hypothalamus detects a decrease in oestrogen levels
- Hypothalamus releases GnRH
- GnRH stimulates pituitary gland to release FSH and LH
- FSH and LH cause development and release of follicles and mature egg
- 2.5-7.5mg daily on days 3-5 of menstrual cycle
- adv: Common: bone pain/carpal tunnel, vaginal dryness, hot flushes , reduced BMD
- Rare: insomnia, raised liver enzymes
- BMD measurement is recommended for long term therapy and Vitamin D and Calcium supplementation
17
Q
Is SC ovulation induction used in infertility?
A
- yes
- initiated after failure of oral therapies
- SC therapy used with IUI & IVF
- doses adjusted depending on type of therapy and number of follicles required to be produced
- Follitropin
- Recombinant FSH
- Tailored IV therapy per patient
- 50-75 units subcut daily for 14 days
- lutropin
- recombinant LH- used to control LH release and surge
- 75 units subcut for 14 days
- Choriogonadotrophin alfa
- Recombinant HCG used to support luteal phase and coordinate release of mature egg
- 250 microg subcut 36 hours prior to mature egg release
18
Q
Are GnRH agonists used in infertility?
A
- Used as adjuvant therapy with rFSH and rL
- Goserelin, leuprorelin, nafarlin and triptorelin
- GnRH will initially stimulate the pituitary gland to produce FSH and LH – continous administration will inhibit GnRH and reduce ovarian activity – stimulate onset of menopause
- Used for endometriosis pain and fibroids – long term
- Short term – stimulation of follicle production
- Leuprorelin used subcut: common
- Nafarelin used intranasally: common
- can be used in conjunction with follitropin & lutropin
19
Q
WHat is timed intercoursE?
A
- following low dose hormonal therapy
- close monitoring of blood tests and endometrial lining is managed by fertility clinics
- when ovulation timeframe is suspected – timed intercourse will be advised to ensure success of egg fertilisation
- Failure of hormonal therapy and timed intercourse
- IUI
- IVF
20
Q
What is ART?
A
- assisted reproductive therapy
- artifical insemination is where the sperm is put directly into the uterus
- it ensures sperm are able to pass the cervix and enter the uterus to locate a mature egg for fertilisation
- intrauterine insemination
- healthy sperm are placed into the uterus around ovulation
- Procedure is done in combination with hormone therapy or tracking methods
- Sperm are centrifuged to remove any abnormal sperm and health sperm inserted
- Effective method for sperm motility problems
21
Q
WHat is in vitro fertilisation?
A
- IVF
- when a human egg is fertilised with sperm in a laboratory
- What are the indications?
- Endometriosis unresponsive to hormonal therapy
- Tubal damage
- infertility for more than 3 years and women over 36 years
- Male infertility
- Unexplained infertility
- lifestyle modifications recommended
- emotional & mental support
22
Q
What are the stages of IVF?
A
- Egg production stimulated by hormone therapy
- Eggs retrieved from ovary
- Sperm sample provided
- Eggs & sperm combined to allow fertilsation
- Fertilized eggs introduced into uterus
23
Q
What medications are used for IVF stages?
A
- Ovarian Stimulation
- rFSH and rLH
- doses tailored to achieve a number of eggs (10-15 eggs)
- days 2-14 of cycle
- GnRH antagonists
- Ganirilex, cetrorelix
- Used to suppress pituitary gland and prevent premature release of developing follicles
- Day 6-14 of cycle
- Ovulation Trigger
- rHCG – choriogonadotrophin
- given 36 hours prior to egg retrieval – initiates release of eggs
- oocyte aspiration achieved medically
24
Q
The fertilisation stage of IVF?
A
- Prepared sperm sample will be added to collected oocytes – fertilisation to occur in incubator
- Eggs are monitored for fertilisation
- Fertilised eggs are monitored until a viable ‘blastocyst’ is achieved – this is then transferred into the uterus
25
Q
What is luteual phase support?
A
- progesterone to help thicken the endometrium and support embryo development
- progesterone pessaries can be used to ensure adequate luteal phase support
- progesterone vaginal pessaries
- 200g PV daily to BD
- can be given rectally
26
Q
What is ICSI?
A
- intra-cytoplasmic sperm injection
- a procedure that directly places the sperm into the mature egg to ensure sperm has entered
- used when sperm has difficulty penetrating egg wall
- increased likelihoof of fertilisation
27
Q
What is ovarian hyperstimulation?
A
- rare side effect of iVF
- severe & requires medical attention
- Multiple follicles (> 17) results in immune response causing ascites, oedema and pleural effusions, sweating, N/V
- Increased risk of thrombosis and reduced renal function
- Managed by adequate hydration and electrolyte balance
- Manage pain and abdominal bloating and discomfort
- Severe OHSS requires hospitalisation
28
Q
Emotional support is important too!!
A
- Cycles of fertility and infertility raise a number of emotions in couples
- Periods of success and failure
- Refer patients of concern
- Utilise IVF support groups!!
