Module 14 - Subfertility Flashcards
Sperm analysis. What is normal semen volume?
Semen volume: Greater than or equal to 1.5 ml
Sperm analysis. What is normal pH?
pH: Greater than or equal to 7.2
Sperm analysis. What is normal sperm concentration?
Sperm concentration: Greater than or equal to 15 million spermatozoa per ml
Sperm analysis. What is normal sperm number?
Total sperm number: 39 million spermatozoa per ejaculate or more
Sperm analysis. What is normal motility?
total motility (% of progressive motility and non-progressive motility): 40% or more motile or 32% or more with progressive motility
Sperm analysis. What is normal vitality?
Vitality: 58% or more live spermatozoa
Sperm analysis. What is normal morphology?
Sperm morphology (percentage of normal forms): 4% or more
When do you repeat sperm analysis if it is abnormal?
If sperm count abnormal repeat in 3 months - to allow time for another cycle of spermatozoa to form
OR
Repeat sperm analysis ASAP if azoospermia or severe oligozoospermia i.e. <5 million sperm/ml detected
Which OHSS can receive outpatient care? How often do they need to be reviewed?
Mild OHSS
Moderate OHSS
Severe OHSS - in selective cases. They will need LMWH
They need to receive appropriate counselling and information regarding fluid monitoring
Review the patient every 2-3 days
What are the criteria for hospital admission of OHSS?
1) Unable to control PAIN
2) Unable to maintain adequate fluid intake, due to nausea/vomiting
3) Worsening OHSS, despite outpatient management
4) Critical OHSS
5) Unable to attend for regular outpatient follow-up
Critical OHSS = ICU input
Can you use diuretics in OHSS?
Only use diuretics if OLIGURIC - despite adequate fluid replacement and ascitic drainage
Get input from the MDT, i.e. ICU
Which fluids should be given to women with OHSS who had had large volumes of ascitic fluid drained by paracentesis?
i.v. colloids
Human Albumin Solution 25% (HAS) - used as a plasma volume expander. Doses of 50-100g given over 4 hours every 4-12 hours
Which increased risks do pregnancies with OHSS have?
Increased risks of:
1) Pre-eclampsia
2) Pre-term delivery
What is the pathophysiology of OHSS? Which features are caused?
Exposure of hyperstimulated ovaries to hCG leads to over-expression of pro-inflammatory mediators, i.e. VEGF (Vascular Endothelial Growth Factor) and other cytokines
Causes:
1) Increased vascular permeability (intravascular fluid depletion, ascites, pleural effusion, pericardial effusion)
2) Increased pro-thrombosis (PE, DVT)
3) Decreased serum osmolality
4) Hyponatraemia
What is the incidence of OHSS?
Mild OHSS - 1/3 of IVF cycles
Moderate - Severe OHSS - 3-8%
Difficult to know the true incidence of OHSS as there is no mandatory reporting of mild and moderate cases and there is no internationally agreed classification system
OHSS is rare following ovarian stimulation with Clomifene (SERM)
OHSS can very rarely occur with spontaneous conception
What are the risk factors for OHSS?
1) Previous OHSS
2) PCOS
3) Increased AFC (Antral Follicle Count)
4) Increased AMH
What are the definitions of early and late OHSS?
Early OHSS - <7 days from the hCG trigger injection used to promote final follicular maturation prior to egg retrieval
The ovarian response is exaggerated - women have excessive abdominal pain and distension
Late OHSS - ≥10 days from the hCG trigger injection
Usually the result of endogenous hCG from an early pregnancy
Trigger injection response is usually unremarkable
Usually more prolonged and severe than early OHSS
What diagnostic features are characteristic of OHSS?
Increased haematocrit + Decreased serum osmolality + Hyponatraemia = OHSS
What are the differential diagnoses of OHSS?
- Appendicitis
- Ovarian cyst accident
- Ectopic pregnancy
- Bowel perforation
- PID
- Pelvic abscess
What are the categories of OHSS?
Mild OHSS:
- Abdominal bloating
- Mild abdominal pain
- Ovary size <8cm
Moderate OHSS:
- Moderate abdominal pain
- US evidence of ascites
- Nausea +/- vomiting
- Ovary size 8-12cm
Severe OHSS:
- Clinical ascites +/- hydrothorax
- Na+ <135
- K+ >5
- Oliguria (UO <300ml/day or <30ml/hr)
- Hypo-osmolality <282
- Haematocrit >0.45
- Decreased album <35
- Ovary size >12cm
Critical OHSS:
- Tense ascites/large hydrothorax
- ARDS
- VTE
- Haematocrit >0.55
- Oliguria/anuria
- WCC >25
What are the life-threatening complications of OHSS?
1) Renal failure
2) ARDS
3) VTE
4) Haemorrhage from ovarian rupture
What is the recovery period like for OHSS?
In most women OHSS is self-limiting and resolves over 7-10 days
If the woman becomes pregnant then the endogenous hCG usually makes it worse
If she doesn’t become pregnant then recovery occurs by the time she has a withdrawal bleed
What do you need to assess during a woman with OHSS daily review?
1) Abdominal girth - ensure it’s not increasing
2) Body weight - ensure it’s not increasing
3) Fluid monitoring - ensure she’s not oliguric and passing >300ml/day or >30ml/hr
4) Bloods - FBC, U&Es, LFTs, osmolality, CRP
5) LMWH
When do you need to seek help from ICU/MDT in OHSS?
If persistent haemoconcentration and oliguria despite adequate fluid hydration
They may prescribe diuretics to improve urine output
What is the maximum amount of fluid that can be drained by paracentesis in women with OHSS?
There is no set limit of the amount of fluid that can be drained by paracentesis
Women with OHSS are typically younger and able to tolerate removal of larger quantities of fluid/ascites
If you remove a large volume of ascites - give i.v. colloids for replacement
Early drainage of ascites to decrease intra-abdominal pressure in patients with moderate-severe OHSS may prevent progression of disease and lower the risk of severe complications
What is the incidence of VTE in OHSS?
0.7 - 10%
How long do you give VTE prophylaxis for in severe OHSS?
At least until the end of the 1st trimester
Where does thrombosis frequently affect in OHSS? How do they present?
Thrombosis in OHSS typically affects the upper limbs and arterial system
Suspect it if a patient presents with: dizziness, neck pain and loss of vision
Which form of OHSS has a higher miscarriage rate? Early or Late OHSS?
Early OHSS
What ovarian complications can arise from OHSS?
1) Ovarian torsion
2) Ovarian rupture
OHSS increases the size and vascularity of ovaries, especially if pregnant
In IVF pregnancies is there an increased risk of miscarriage with OHSS?
No
There is no increased miscarriage rate with OHSS vs. non-OHSS IVF
What proportion of the general population will conceive within 1 year?
80% of the general population will conceive within one year if:
- Women is <40 years old
- They do not use contraception and have regular sexual intercourse
What proportion of the general population will conceive within 2 years?
Of the 20% of the general population who do not conceive within the 1st year, half of them (10%) will conceive in the second year (90%).
Therefore, 90% of the general population will conceive within 2 years if the woman is <40 years, are not on contraception and have regular SI
What is the definition of infertility?
A woman of reproductive age who has not conceived after 1 year of unprotected vaginal sex
What is the incidence of infertility in the UK?
Infertility affects 1 in 7 heterosexual couples in the UK
What are the success rates with artificial insemination?
- > 50% of women <40 years will conceive with 6 cycles of intrauterine insemination (IUI)
- 58% of women <30 years will conceive after 6 cycles of IUI
- Of those who do’t conceive with the first 6 cycles, half will conceive with a further 6 cycles
What is the recommended frequency of vaginal sexual intercourse to optimise the chance of pregnancy?
2-3x per week
If you have sex 3x per week - it increases your chance of pregnancy by 50%
What are the recommendations for alcohol in couples with subfertility trying to conceive?
Women - decrease drinking to 1-2 units/week to decrease the harmful effects to the fetus (which may not be known)
Also avoid being drunk (episodes of intoxication)
Men - drinking Department of Health’s alcohol intake recommendation (<14 units/week spread over 3 days or more) shouldn’t affect semen quality
However, excessive alcohol decreases semen quality
What are the recommendations for smoking in couples with subfertility trying to conceive?
Women - smoking likely decreases fertility
Offer smoking cessation programmes
passive smoking likely decreases fertility
If patient referred for IVF and is smoking, you discharge back to GP. Patient needs to complete smoking cessation for 3/12
Men - smoking decreases semen quality
Stopping smoking will improve overall general health
What are the recommendations for caffeine in couples with subfertility trying to conceive?
No consistent evidence that consumption of caffeinated beverages (coffee, tea, colas) affects fertility
Caffeine may be linked to IUGR
What is the effect of obesity on fertility?
BMI >30 - can take longer to conceive (for both men and women). Won’t receive NHS-funded IVF
Increased miscarriage rates by 50%
Adipose tissue stores hormones (oestrogen) - so decreased ovarian response
If BMI >30 + anovulation - weight loss will likely increase their chance of conception
Women participating in group programmes focusing on diet and exercise lead to more pregnancies than weight loss advice alone
BMI <30 in men - increased semen quality
What is the effect of low body weight on fertility?
Women with BMI <19 with oligomenorrhoea or amenorrhoea - advised that increasing body weight may improve their fertility
BMI <19 - don’t offer IVF
What is the effect of tight underwear on fertility?
Tight underwear = increased scrotal temp = decreased semen quality
Uncertain whether wearing loose-fitting underwear improves fertility
What dose of folic acid is recommended in women with subfertility?
3 months prior to conception and up to 12/40 gestation women with subfertility should take Folic acid 400 micrograms OD
Take 5mg OD if:
- Diabetes
- WWE on AEDs
- Previous history of NTD
When should women who have been trying to conceive be referred/offered further clinical assessment and investigation?
GPs investigate for infertility in women of reproductive age who have been trying to conceive for ≥1 year
Women who have received 6 cycles of artificial insemination (IUI or ICI) with partner or donor sperm and have not conceived
Which women do you offer earlier referral for IVF for?
1) >36 years old
2) Known cause of infertility or a history of predisposing factors for infertility
3) Having Chemotherapy
Which markers are used to predict the likely ovarian response to gonadotrophin stimulation in IVF?
Use any one of the following:
1) Antral Follicle Count - how many follicles seen on scan. Can fluctuate month-to-month
low response - ≤4
high response - >16
2) AMH
low response - ≤5.4 - do not offer IVF
high response - ≥25 - risk of OHSS
3) FSH
low response - >8.9 - do not offer IVF
high response - <4
What test(s) do you use to confirm ovulation?
Mid-cycle serum progesterone - perform this on Day 21 (mid-luteal phase)
If progesterone >30 = ovulation
If you have prolonged irregular cycles then perform a mid-cycle serum progesterone, day 2-3 FSH and LH
i.e. for a 35 day cycle perform progesterone at Day 28 (as ovulation is always 14 days before menses)
Basal body temp - is not a reliable method to confirm ovulation, therefore is not recommended