Obs & Gynaecology - Ifertility basics

Question 1

Classifications

Primary vs. secondary

• Primary: Never previously conceived
• Secondary:…

Male factors vs female factors

Surgical sieve:

–Congenital vs acquired

–Acquired: MEDIC HAT PINI

–metabolic/endocrine/degenerative/infection/congenital/haematological/autoimmune/traumatic/psychological/inflammatory/neoplastic/mechanical/idiopathic

Iatrogenic

Answer 1

Causes

Metabolic:

Obesity (gross)

Anorexia

Uncontrolled diabetes

Renal failure

Question 2

Endocrine

Ovarian

Ovarian failure including early menopause

• XXO
• XY with testosterone resistance

Non-ovarian

• Thyroid!! Hyper and hypo
• Hyperprolactinaemia and other pituitary issues
• Adrenal failure

Male

• Gonadal failure (e.g. secondary to mumps)

Answer 2

Infection

• GC
• Chlamydia
• Appendicitis
• Result in mostly ‘obstructive’

Question 3

Congenital

• Absence of uterus
• XO
• Etc.

Answer 3

Haematological/autoimmune/traumatic

• Hmm
• Autoimmune: as part of broader syndrome/unwellness
• Trauma: obvious

Question 4

Psychological/inflammatory/neoplastic

Psychological

• Vaginismus
• Lack of libido
• Depression

Inflammatory

• Reaction to infection eg chlamydia

Neoplastic

• Uterine/cervical/ovarian ca
• Rarely relevant here
• ‘mole’: usually benign but can become malignant; v rare

Answer 4

Idiopathic/iatrogenic

• Many cases of infertility are idiopathic, ie no reasonably attributable cause
• PCOS: ¼ women have some evidence on ovarian scans
• Polycystic ovary syndrome (PCOS) is a set of symptoms due to elevated androgens (male hormones) in women

Anovulation (ovaries do not release an oocyte during a menstrual cycle. Therefore, ovulation does not take place.)
Hirsutism
Amen; oligomenn;
Diagnosis: history, exam, LH, FSH, testosterone assays; U/S
Endometriosis
Iatrogenic: rare (NOT post OC)

Question 5

Endometriosis

Answer 5

Endometrium in ‘wrong’ site

• E.g. ovaries, tubes
• Causes pain and adhesions
• Hence (usually) Fallopian tube dysfunction

Question 6

Treatment of Infertility?

Answer 6

• According to cause
• Ry or ameliorate endocrine/metabolic etc
• For endometriosis:

–pregnancy!; danazol; GnRH blockers

• Male causes; azoospermia or low sperm count or ED or psychological
• Gamete donation for male causes
• Advice (inverse of natural family planning)
• +/- hormonal adjunct eg LH surge test (36 hours to go!)

Question 7

Ovarian Issues?

Answer 7

• Clomiphene (for PCOS)
• Ovarian stimulation to ovulate
• Or harvest!
• ‘test-tube baby’
• With or without partner sperm (note especial cases, freezing sperm, aspiration of sperm)
• ICSI

Question 8

Summary

Answer 8

• Moderately common
• Immensely stressful for couples of all kinds
• Some simple steps:

–History (eg primary vs. secondary)

–Advice

–Patience (but care if older)

–Simple tests

• Sperm count, progesterone, PCOS screen (bloods and u/s)
• Clinical examination of male and female