Module 1.2.1 (Management of Infertility) Flashcards
(35 cards)
What is primary infertility?
infertility: indicates that the ability to become pregnant maybe diminished or absent.
subfertility: delay to conceiving
1 in 6 couples have trouble conceiving (15%) with 50% of these requiring medical assistance
Defined as failure to achieve a pregnancy after 12 months of regular, unprotected intercourse (2-3 per week)
> 85% of couples are likely to conceive in 12 months and upto 95% in 24 months
What is seconday infertility?
Defined as failure to achieve a second pregnancy after a couple has already had a pregnancy or child.
What are examples of ovulation disorders that can cause female infertility?
Decreased ability to release a viable egg for fertilisation, can be due to hormone deficiency
- Ovary damage
- Infrequent periods (oligomenorrhoea)
- Absence of periods (amenorrhoea)
How can blocked/damaged fallopian tubes cause female infertility
- Blocked tubes – hysterosalpingogram (HSG) –> do to see if tubes are blocked
- Damage due to previous surgery – results in scar tissue deposits
- Limited egg flow and sperm access
- Pelvic inflammatory disease (PID) due to sexually transmitted diseases e.g chlamydia, gonorrhoea is a significant cause of tube damage
How can endometriosis cause female infertility?
- Significant cause of infertility
- Uterine tissue grows outside the uterus and can affect the ovaries, fallopian tubes, bowel, bladder and rectum
- Development of scar tissue in the uterus that can impair embryo attachment
Why does fibrioids cause female infertility?
- Can occur in 70-80% of women
- Non-cancerous growth of muscle in the uterus that may affect fertility/implantation
Why can PCOS cause female infertility?
Polycystic ovarian syndrome – ovaries are enlarged and have a thicker outer layer covered by small cysts – can be harmless but affect period regularity and result infertility
How does cervical problems cause female infertility?
Cervical secretions
> production, consistency and resistance
Causes of male infertility?
- Damage to sperm production – oligospermia/azoospermia
- Obstruction to the vas deferens
- Testosterone production
- Sperm genetics
- Sperm abnormalities / mobility problems n Damage due to cancer therapy
What are some lifestyle factors that can cause infertility?
Smoking
- Women – increased risk of ovulation problems and miscarriage
- Men- may affect development, quality and volume of sperm
Alcohol
- Excessive alcohol intake can 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 recreational drugs 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
Fertilitity and age?
Female fertility is known to decrease with age
Women are most fertile between the ages of 15-25 years
From 35 years of age – the quantity and quality of viable eggs will begin to decrease
By 50/60 years of age, the total number of eggs available will have usually depleted
n In contrast – male fertility can persist into old age – some evidence to suggest a reduction of sperm quantity and quality at 45 years of age
Describe the
A) menstrual phase
B) follicle phase
C) ovulation phase
D) luteal phase
A)
- • Days 1-5 •
- Menstrual bleed •
- Break down of endometrium – endometrial lining
B)
- Day 5-14 •
- Pituitary Hormone/ Gonadotrophin Release •
- FSH release to stimulate follicle development •
- Follicle development increases Oestrogen release from the ovaries
C)
- Day 14-16
- Release of mature egg from ovary
- Ovulation is triggered by the release of LH
- Ovulation/fertile window
D)
- •Day 17-28
- Follicle develops into a corpus luteum - Initiates release of progesterone – increase in endometrium thickness
- Fertilised egg will embed in lining and release HCG – positive pregnancy
- •If no pregnancy, corpus luteum demise/ decreased progesterone
- Endometrial lining breakdown - menstrual phase
What are the FOUR stages of fertility treatment?
- Lifestle modifications –> fertility tracking
- Ovulation Induction –> hormonal therapy
- Assisted reproductive technology (ART) –> Artificial Insemination (AI) and Intrauterine Insemination (IUI)
- In Virtro Fertilisation (IVF). IVD with intra-cytoplasmic sperm injection (ICSI).
How to modify lifsetyle?
- Balanced diet
- No smoking
- No alcohol
- Weight management
- No drugs
- Include physical actvities
- Regular and adequate sleep
- Multivtiamins and folic acid
For fertility tacking which is part of lifestyle modifications, describe the following types:
A) Cycle tracking
B) Basal body temperature
C) Changes in cervical mucus
D) Ovulation Kits
A)
- 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
B)
- Following ovulation – temperature is expected to rise significantly due to the increase in progesterone levels
- Monitor daily temperature throughout cycle and record days where body temperature has risen
C)
- 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
D)
- 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
What is ovulation induction? What are the methods of it?
Ovulation Induction utilises oral or intravenous medications to stimulate the ovaries to produce follicles that will mature into a viable egg that can be fertilised
> Used for an-ovulation (not releasing egg) or decreased luteal phase support
Methods
- COC
- Metformin in PCOS
- Clomiphene
- Letrozole
- GnRH Agonists
- GnRH Antagonists
How does COC help with ovulation induction? Which one is used?
Low dose combined oral contraceptives can be used to assist with menstrual cycle regulation and allow for adequate tracking during a fertility cycle
Medroxyprogesterone –> regulates cycle
- Synthetic progesterone
- Used in amenorrhea to cause a uterine bleed
- Suppress the LH surge and induce a withdrawal bleed indicating low oestrogen levels in the body –> thus increasing progesterone
- Medroxyprogesterone 10mg daily for 12 days
- Prepare body for ovulation
> if dont have withdrawal bleed after taking progesterone, estrogen levels are low = letrozole and clomiphene unlikely to be effective because estrogen too low for drug to suppress estrogenic feeback on the hypothalamus –> gonadotrophins are preferred
–> estrogen develops the endometrial lining therefore if not enough estrogen –> no endometrial lining
How is metformin in PCOS related to infertility?
- 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
> Metformin IR 500mg bd or tds
- Limited evidence for XR formulations but can be used if GI symptoms not tolerated
Why is clomiphene used to manage infertility? How does it work?
- Used to induce ovulation
- Clomiphene is an oestrogen receptor antagonist
–> decrease in oestrogen = hypothalamus releases GnRH = stimulates pituitary gland to release FSH and LH = cause development and release of follicles and mature egg
- Clomiphene induces the production of one mature egg for fertilisation – close monitoring is required to ensure multiple eggs are not released – 6% risk of multiples pregnancy
- Timed intercourse to achieve a succesful pregnancy
CIR AE of clomiphene? Who are the patients that are unresponsive to clomiphene?
Common: abdominal discomfort, hot flushes, ovarian enlargement and cysts
Infrequent: nausea and vomiting, abnormal uterine bleeding
Rare: visual disturbances, ovarian hyperstimulation syndrome (rare)
Patient’s unresponsive to clomiphene
> increased age
> extremes of body weight
> more than 6 cycles of treatment
How does letrozole help with infertility? What are the AE? What is recommended for long term therapy?
Aromatase inhibitor
- 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
AE
- 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
When is subcutaneous ovulation induction used? What is it used with? How is doses adjusted?
Initiate after failure of oral therapy
- Subcutaneous therapy used with IUI and IVF
- Doses adjusted depending on type of therapy and number of follicles required to be produced
What are the three types of SC ovulation induction used?
Follitropin
- Recombinant FSH
- Tailored IV therapy per patient
Lutropin
- Recombinant LH – used to control LH release and surge
Choriogonadotrophin alfa
- Recombinant HCG used to support luteal phase and coordinate release of mature egg
Follitropin and lutropin combination product available = increases both FSH and LH and means less injections a day
When are GnRH agonists used? How to they work? Short term and long term effects?
Used as adjuvant therapy with follitropin and lutropin
> goserelin, leuprorelin, narfarlin 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
short term - stimulation of follicle production
> leuprorelin used subcut
> nafarelin used intranasally
long term - used for endometriosis pain and fibroids
