OG Case 13 - Infertility Flashcards
Define infertility?
Failure to conceive after 12 months of unprotected intercourse.
Primary infertility?
Couple who has never been able to conceive.
Secondary infertility?
Find it difficult to conceive having already conceived in the past (could have had term pregnancy or may have experienced miscarriage).
How many couples experience infertility?
1 in 5.
What is fecundity?
The capacity to conceive and is measures as the monthly probability of conception.
What is the average monthly chance of conceiving in normal fertile couples?
20%.
What is the average duration for a fertile couple to conceive?
3 months.
What are the lifestyle factors that affect fecundity?
- Smoking - damages eggs, fallopian tubes, sperm, affects hormones in men/women, miscarriage risk, ectopic pregnancy.
- Moderate/heavy alcohol intake.
- Weight - high and low BMI.
- Exercise - none or excessive.
- Medication - steroids.
What are the causes of infertility?
- 33% male factors.
- 20% anovulation.
- 15% tubal factors.
- 10% endometriosis.
- 5-10% cervical factors.
- 15% unexplained.
What are the female causes of infertility in a female?
- Anovulation.
- Tubal factors.
- Cervical factors.
What can be causes of anovulation?
- Premature ovarian failure.
- PCOS.
- Hypothalamic/pituitary insufficiency.
- Hyperprolactinaemia.
- Metabolic disease (thyroid, renal, liver, underweight/obese).
What can be causes of tubal factors?
- PID (1 episode 10%, 3 episodes 50%).
- Previous ecctopic pregnancy.
- Adhesions, endometriosis.
- Peritoneal infections.
What can be causes of cervical factors?
- Congenital.
- Infection.
- Post-surgery.
What topics do you cover in the female infertility history?
- General hx - age, BMI, ethnicity, occupation/environment, folate in diet, smoking, drugs, EtOH.
- Endocrine - acne, hirsutism, dysmenorrhoea, galactorrhea, thyroid, weight gain.
- Intercourse - timing (in relation to ovulation) and frequency (>2x/month).
- Menstrual history - period regularity and frequency, anovulatory periods, signs of androgen excess, STI/PID, heavy bleeding, structural abnormalities.
- Past obstetric history - pregnancies, miscarriage, TOP, gravida/parity.
- Contraception.
- PMHx - fertility, chromosomal disorders.
- SHx - smoking, drugs, stress, libido.
What is the infertile female examination?
- General inspection.
- Height, weight, BMI.
- Vitals - HR, BP, RR, Temp (increases 0.3 degrees post-ovulation), SaO2.
- Endocrine/systemic disease - PCOS (evidence of hirsutism, acne, alopecia, striae).
- Abdomen - shape, scars, tenderness, striae.
- Pelvis -external genitalia, speculum (cervix), +/- smear, pipelle, HVS/endocyx swab, bimanual (uterine size, tenderness, adnexal masses).
What investigations do you do for an infertile female?
- Hep B, rubella, chlamydia, gonorrhoea screen.
- FBC.
- Hormone.
- USS - view follicle development or change to secretory endometrium, fibroids, endometriosis, masses, PCOS.
- Laparoscopy/hysterosalpingogram - assess tubal patency.
- Prolactin - produced by pituitary, increased levels interfere with ovarian function.
What are the hormones that you test?
- Day 2-4 FSH/LH (LH is elevated days 2-5).
- Day 21 progesterone (mid luteal rise >30mmol/L in 3 cycles).
- Testosterone.
- LH:FSH ratio.
- TFT - hypothyroidism.
- Prolactin - produced by pituitary, increased levels interfere with ovarian function.
What are the causes of infertility in males?
- Sperm.
- Anatomical.
- Endocrine.
- Sexual dysfunction.
What are the causes of infertility due to sperm?
- Abnormal spermatogenesis - secondary to mumps, orchitis, chromosomal abnormalities, chemical/radiation exposure.
- Oligospermia/azoospermia.
- Abnormal morphology or motility.
What are the anatomical causes?
- congenital.
- Obstruction of vas deferens.
- Varicocele - varicosities in spermatic cord veins.
- secondary to infection - mumps, STIs, prostatitis.
- Surgery or trauma.
What are the endocrine causes?
- Hyperprolactinaemia.
- Hypothalamic or pituitary failure - tumour, radiation or surgery.
- Exogenous androgens.
- Adrenal hyperplasia.
What topics do you cover in the infertile male history?
- Intercourse - frequency.
- Erection/ejaculation problems.
- Pubertal development.
- Previous fatherhood.
- Previous STI.
- Previous surgery - especially GU tract.
- SHx - smoking, EtOH, environmental toxins, illicit drug use.
What is the infertile male examination?
- Evidence of gynaecomastia, eunuchoidal features (testes are present but fail to function normally; may be of gonadal or pituitary origin).
- Secondary sexual characteristics.
- Genital examination (particularly testicular volume/size, vas deferens palpation).
What investigations do you do for an infertile male?
- Semen analysis:
- volume >2mL.
- density >20mil/mL.
- motility >50%.
- normal morphology >70%. - Blood tests:
- FSH (primary testicular failure, pituitary dysfxn).
- Testosterone + LH (androgen deficiency).
- Karyotyping (exclude chromosomal abnormality). - Toehr swabs for chlamydia and gonorrhoea, post-coital test (>20 motile sperm/HPF).
How do you manage infertility?
- Depends on aetiology.
- General measures:
- coital timing (every 2 days in peri-ovulatory period, days 12-16). - Emotional support.
- Lifestyle factors - stop smoking, weight loss, healthy diet, caffeine reduction.
What are specific measures for PCOS?
- Weight loss.
- Clomiphene citrate (anti-oestrogen, increases FSH in early follicular phase).
- Metformin (improves insulin sensitivity).
- Recombinant FSH (direct ovarian stimulation, risk of multiple pregnancy).
What are specific measures for tubal disease?
Hysterosalpingogram, manual removal or balloon tuboplasty, IVF if severe.
What are specific measures for endometriosis?
IVF.
