Management of Infertility Flashcards
What is the definition of infertility
Failure to conceive despite regular unprotected sexual intercourse over 12 months in absence of known reproductive pathology
Why is infertility classed as a disease
It causes considerable psychological distress
What are some factors that influence fertility
Female age
Duration of infertility
Previous pregnancy
Cause of infertility
What are some reasons for the incidence of infertility increasing
Older women rise in increase in chlamydia infections increase in obesity increasing awareness of treatments change in expectations increasing male factor infertility
What should be involved in the examination of a female in the infertility clinic
BMI BP Urinalysis General examination Pelvic examination
What should be involved in the examination of a male in the infertility clinic
BMI BP Urinalysis General examination Urogenital examination
What type of drug can cause an increase in prolactin
Antidepressents
What types of drugs can cause a problem with Ovulation
NSAID
What investigations are required for the female
Endocervical swab for chlamydia
Cervical smear if due
Blood for rubella immunity
Midluteal progesterone level
What 3 things can Rubella syndrome cause to the newborn
Microcephaly (small head) PDA (heart abnormalities) Cataracts Rash at birth Low birth weight
What type of vaccine is the Rubella vaccine
Live
What is the treatment for chlamydia
Azithromycin tablet 1g
What are some short-term affects of pelvic inflammatory disease
Tub-ovarian abscess
Peritonitis
Fitz-Hugh-Curtis Syndrome
What are some long-term affects of pelvic inflammatory disease
Chronic pelvic pain
Infertility
Ectopic pregnancy
What is the treatment for an ovarian abscess
Surgically drain the abscess and prescribe broad spectrum Antibiotics for 2 weeks
What is a strong suggestion of ovulation
Regular menstruation
What can we measure to confirm ovulation in someone with regular cycles
Midluteal serum progesteron
What are the 3 groups of ovulatory disorders
Group 1 - Hypothalamic
Group 2 - Hypothalamic Pituitary dysfunction
Group 3 - Ovarian Failure
What are some of the causes of Hypothalamic ovulatory disorders
Stress Excessive exercise Anorexia Kallman's syndrome Isolated gonadotrophin deficiency
What is the most common type of ovulatory disorders
Hypothalamic pituitary dysfunction including PCOS
What are some symptoms of PCOS
Hirsutism Acne/ oily skin Increase in testosterone levels Oligomennorhoea Central obesity
What is seen on US to confirm Polycystic ovary
More than 12 follicles between 2-8 mm in diameter in a single plane
Patients must have 2 of what to make a diagnosis of PCOS
Irregular menstrual cycle, hirsuitism, acne, sub fertility, alopecia, obesity Biochemical- in days 2-5 Elevated serum LH LH/FSH >2 Normal estradiol Low progesterone Normal or mildly elevated prolactin Raised testosterone
What are the first line drugs used to induce ovulation
Antioestrogens e.g. Clomifene citrate or tamoxifen
Aromatase inhibitors e.g. Letrozole
How should Clomifene citrate be taken
Day 2-6 of cycle (1 tablet for 5 days)
What is the advantage of using Tamoxifen to Clomifene citrate
The oestrogen effect on endometrium
How do Aromatase inhibitors work
They inhibits ovarian aromatase enzyme
What are some second line treatments for inducing ovulation
Clomifene citrate + metformin (to improve sensitivity) Gonadotrophin therapy (daily injections) Laparoscopic ovarian diathermy
What do we look for when examining sperm
Volume >1.5ml
count >15x 10^6/ml
Progressive motility and >4% normal morphology
What is the most common cause of male infertility
Idiopathic
What are some obstructive causes of male infertility
Vasectomy
Infection
Congenital absence of vas deferens (Cystic Fibrosis)
What are some of the non-obstructive causes of male infertility
Undescended testis
Orchitis
Torsion/trauma
Chromosomal (Kleinfelter’s syndrome 47XXY)
What are some other causes of male infertility
Hormone - hypothyroidism, hypogonadism, hypogonadotrophic, testicular cancer
Chemo, radio, erectile dysfunction, immunological
What are the treatment options for male infertility
Surgery to obstructed vas deferins
Intrauterine insemination
Intracytoplasmic sperm injection (ICSI)
Donor insemination
What are the most common causes of tubal disease
Infective:
Pelvic inflammatory disease inc. chlamydia or gonorrhoea
What are some non-infective causes of the tubal disease
Endometriosis Surgical Fibriods Polyps Congenital
What are the treatment options for tubal disease
Tubal surgery (reversal of sterilisation) IVF
How are eggs collected for IVF treatment
Ultrasound guided
How big is a blastocyst and at what stage does this form
More than 125 cells - blastocyst
What are some general factors for improving the likelihood of pregnancy
Sex 2-3 times per week Low alcohol intake Between 19-29 BMI No smoking Folic acid Rubella immunity Cervical smears up to date
