Obs&Gyn: Infertility Flashcards
Simple description of menstrual cycle
Spermatogenesis
Define infertility
Failure to conceive after regular unprotected sexual intercourse for 1 year in the absence of known reproductive pathology
Subfertility - conceiving is possible but takes longer (is delayed)
Advice on frequency and timing of sexual intercourse
- intercourse every 2 to 3 days optimises the chance of pregnancy
- Timing intercourse to coincide with ovulation (ovulation testing kits) causes stress and is not recommended
Lifestyle advice for a couple trying to conceive/ struggling with infertility
- Drinking no more than 1 or 2 units of alcohol once or twice a week and avoiding episodes of intoxication – “binge drinking”
- Excessive alcohol consumption is detrimental to semen quality
- Smoking is likely to reduce fertility in women and men (impotence, and congenital abnormalities)
- BMI > 29 or more is associated with reduced fertility in men and women
- Rubella screening and regular folic acid
- Dietary advice
Infertility factors statistics (%) by gender
Female factor – 40%
Male factor – 30%
Combined – 30%
Female causes of infertility
- Uterus and tubes
- Cervical mucus
- Fallopian tube damage
- Uterine fibroids/septum
- Ovulation Disorders
- Medicines, drugs and medical disorders
- Age
Male causes of infertility
- Sperm disorders
- Testicular disorders
- Ejaculation problems
- Medicines and drugs
General History taking points
- Both partners should be present
- Age
- Previous pregnancies by each partner
- Length of time without pregnancy within current relationship
- Sexual history
- Frequency and timing
- Use of lubricants
- Impotence, dyspareunia
- Contraceptive history
What to ask about in the history from male?
- Occupation – use of toxins/pesticides/cadmium/mercury/long distance lorry driver
- Alcohol, smoking
- Showers vs baths – excessive heat exposure
- Sexual development and structural anomalies
- Surgery – hernias/varicocele/prostate
- Orchitis (mumps)
- Systemic illness or viral illness
- Erectile dysfunction (IDDM, MS, paraplegia/drugs)
- Drugs – anti-androgens, chemotherapy, anabolic steroids
What to ask about in history from female
- Menstrual history e.g. LMP, cycle, onset
- Gynae history – smears, contraception, previous pregnancies, PID/STI, appendicitis, IUD use, ectopic pregnancy history/tubal surgery, endometriosis, cervical and uterine surgery, sterilisation
- PMH – chronic conditions eg. Diabetes, thyroid disorders
- SH – alcohol, smoking, illicit drugs
- FH – PCOS, congenital abnormality
- Stress
- Exercise
- Weight changes
What couples not to investigate for infertility problems?
- Patient not sexually active
- Patient not in long term relationship
- Patient declines treatment at this time
- Couple does meet the definition of an infertile couple
- Very young
What to look at during physical examination in male?
- Size of testes
- Testicular descent
- Varicocele
- Outflow abnormalities (hypospadias)
- Thickened epididymis
What to look at during examination in female?
- Pelvic masses
- Abdomino-pelvic tenderness
- Uterine enlargement
- Thyroid examination
- Uterine mobility
- Cervical abnormalities
- Utero-sacral nodularity
Bloods in Ix for infertility
- Confirmation of ovulation – “day 21” progesterone
- Follicular phase bloods – day 2-4
- FSH, LH, oestradiol, prolactin, testosterone, DHEAS, androstenedione, SHBG, FAI
- Rubella and chlamydia serology
Ix for tubal potency
Evaluate tubal patency whenever there is a history of PID, endometriosis or other adhesiogenic condition
Tests:
- Hysterosalpingogram
- Hycosy (hystero-salpingo contrast sonography)
- Laparoscopy and dye test
Describe Hysterosalpingogram (HSG)
- Radiologic procedure requiring contrast
- Performed optimally in early proliferative phase (avoids pregnancy)
- Oil-based contrast (higher risk of anaphylaxis)
- Can be uncomfortable
- Pregnancy test advisable
- Can detect intrauteine and tubal disorders but not always definitive
Describe HyCoSy
Hystrosalpingo Contrast Sonography
- Transvaginal ultrasound technique
- Contrast solution of galactose (Echovist) is infused into the uterine cavity and observed to flow along the fallopian tubes to assess patency
- HyCoSy needs to be carried out between day 8 and 12 of a natural unprotected menstrual cycle or anytime in the cycle if reliable contraception is used
Male investigations
- Semen Analysis
- If semen analysis normal consider
- FSH/LH
- Testosterone
Criteria for semen analysis
- Semen analysis after abstinence from sex for 4 days
- Repeat test should be offered only after 3 months
- In presence of gross abnormality – sooner, or as soon as possible
- To the lab ASAP (< 60 mins) kept at body temperature
Interpretation of serum progestogen
Management of infertility
- If investigations normal and couple trying for short time – reassure
- If relatively young “wait and see” policy for 2 years
- Anovulation → clomiphene (an ovulatory stimulant) or tamoxifen
- Metformin if PCOS
- Ovarian drilling
- Tubal problem – IVF
- Male factor – testicular biopsy, ICSI (intracytoplasmic sperm injection), donor insemination
Assisted reproductive techniques list
- IUI (intrauterine insemination
- IVF (In vitro fertilisation)
- ICSI (intracytoplasmic sperm injection)
- Donor insemination
- Egg donation
- Egg freezing
- PGD (preimplantation genetic diagnosis) used in couples with history of genetic disorder
IVF vs IUI
IVF vs ICSI
Types of dysmenorrhoea
- primary → coming with period (e.g. lower abdominal cramps)
- secondary → coming few days before bleed and finishing few days after (maybe pathological e.g. adenomyosis, endometriosis)
Types of dyspareunia
- superficial → as the penis enters e.g. vaginismus (psychological)
- deep → pathological e.g. cervical cancer, ectropion
Why do we do bloods in 2-3 day of a menstrual cycle?
They are then at a baseline level
(to check for hormonal baseline)
Types of infertility (2)
- Primary → a person never has had kids
- Secondary→ a person has had a child but can’t get pregnant again
Why Day 2 FSH may be higher in older ladies?
It is higher as more FSH needed to stimulate poorly responsive follicular maturation
Class and MoA of Clomiphene
Clomiphene is anti-oestrogen
it works via negative feedback → less oestrogen = more FSH will be produced → ovulation
Difference between ICSI and IVF
- ICSI → sperm taken and injected into the egg cell
- IVF → sperm and egg in one dish; sperm needs to penetrate egg itself
Characteristics of ovarian cyst in PCOS
- dense stroma
- ‘pearl necklace’ appearance (immature follicles)
- hydrodese shell/capsule
What about testosterone and SHBG levels in PCOS?
- SHBG levels low → as more testosterone is bound to it (so less saturated)
- Testosterone level is high
What’s a typical LH:FSH ratio in PCOS?
LH: FSH ratio in PCOS is typically 3:1
Do we give any fertility treatments to a woman with BMI >30?
No! If a woman would get pregnant her BMI increases even further → so more harm than good
We first need to get woman’s BMI to 30 or less
Outline steps in management of infertility in PCOS
- lifestyle (to get BMI to 30)
- Clomiphene/ Tamoxifen
- Metformin
- referral (if the above don’t work)
(2) differentials for a woman with high testosterone
- Congenital Adrenal Hyperplasia
- PCOS
After what period of time do we repeat sperm analysis?
only after 3 months as sperm need to replenish itself
