PBL 1 Flashcards
Define the term subfertility
Defined as the inability to conceive for 12 months (up to 24 months) after commencing unprotected regular intercourse.
How many couples conceive in the period of 24 months
- 80 percent conceive in the first year
- then out of the remains 20%, 50% conceive in the next year
what are the types of subferitlity
primary subfertility
secondary subfertility
define primary subfertility
no previous pregnancy
define secondary subferitlity
previous pregnancy (whatever the outcome).
what is the monthly probability of pregnancy
0.4 (reciprocal of average time required for conception in months).
name maternal causes of subfertility
- pelvic inflammatory disease
- endometriosis
- fibroids
- PCOS
what can subfertility be due to
- male
- female
- combined factors
name different causes of subferilityt
- ovulatory causes (25%)
- tubular and uterine causes (30%)
- male factors (30%)
- unexplained subfertility (20%)
what are the three types of ovulatory causes
Type 1: Hypopituitary failure e.g. anorexia.
Type 2: Hypopituitary dysfunction e.g. PCOS, Hyperprolactinaemia
Type 3: Ovarian Failure (Premature OF if under 40 years).
describe how you manage type 1 hypopituitary failure
Type 1: Hypopituitary failure anorexia.
• Management increase weight, decrease exercise
o Consider pulsatile GnRH.
what is the most common cause of anovultaroy infertility
PCOS (polycystic ovarian syndrome)
what is PCOS characterised by
mild obesity
what is the diagnostic criteria for PCOS
• Oligomenorrhea (infrequent menstrual periods) OR amenorrhea (absent).
• Clinical hyoerandrogenaemia (hirsutism and acne).
o Raised LH with normal FSH, raised testosterone.
• Polycystic ovaries on ultrasound (>12 follicles measuring between 2 and 9mm diameter).
o And/or ovarian volume >10ml.
what is the difference between olgiomenorrhea and amenorrhea
• Oligomenorrhea (infrequent menstrual periods) OR amenorrhea (absent).
what is the cause of PCOS
- believed due to be because of insulin resistance
- this leads to hyperinsulinaemia
- and increased androgen production of theca cells
how do you manage PCOS if the patient wants of conceive
- weight loss if the patient is overweight
- clomiphene; ovulation induction
surgery
- ovarian drilling
- wedge resection
how do you manage PCOS if the patient does not want to conceive
- low contraceptive pills (restore menstural regulatory)
- metformin
- anti-androgens (such as cyproterone acetate)
what does metformin benefit
- metformin seems to be benefiting the women undergoing IVF treatment
describe ovarain failure
Type 3: Ovarian Failure (Premature OF if under 40 years).
• OF involves persistent FSH raised.
• Management: donor eggs/alternative parenting.
what is pelvic inflammatory disease
• Severe inflammation of the peritoneal cavity caused by infection spreading from the vagina and cervix to the uterus, oviducts (Fallopian Tubes), ovaries and pelvic area
what is the diagnostic criteria of pelvic inflammatory disease
- May be asymptomatic
- Pelvic pain, dyspareunia (painful sexual intercourse), fever.
- Cervical excitation: touching the cervix causes painful reaction.
what are the causes of pelvic inflammatory disease
STIs such as chlamydia (C. trachomatis) and gonorrhoea (Neisseria gonorrhoeae
what is the management of pelvic inflammatory disease
Management: antibiotics, rest and abstinence
what is endometriosis
• Presence of tissue histologically like endometrium outside the uterine cavity
what is the diagnostic criteria of endometriosis
- Pain
- Dysmenorrhoea (painful menstruation).
- Menorrhagia (abnormally heavy bleeding)
- Dyspareunia (difficult/painful sexual intercourse).
what is the management of endometriosis
- NSAIDs
- COPC (combined oral contraceptive pill)
- GnRH Agonists
- Surgery
what are fibroids
• Benign tumours of smooth muscle of the myometrium (uterine leiomyoma).
what are the symptoms of fibroids
o Complain of heavy, regular periods.
o Can grow to cause menorrhagia, dyspareunia.
How do you treat fibroids
Treatment:
• Nothing.
• Medical: analgesia, COCP, progesterone intra-uterine devices.
• Radiological: embolization, radio-frequency ablation.
• Surgery: hysterectomy, uterine artery ligation
What are the different locations of fibroids
submucosal, subserosal, intramural
give examples of tubule and uterine causes of infertility
- pelvic inflammatory disease
- endometriosis
- fibroids
what are male causes of subfertility
- Testicular - infection, cancer, surgical, congenital and trauma
- azoospermia - absence of motile sperm
- reversal of vasectomy
- ejaculatory problems (retrograde and premature)
- hypogonadism
what are cortical problems
- Dyspareunia (painful sexual intercourse).
* Coital Frequency <3 times a week (3-4%).
describe unexplained infertility
• Do not offer clomiphene: no increased chance of pregnancy/live birth.
o Continue having regular unprotected intercourse.
Offer IV after 2 years
what drugs are linked to infertility
Female: long-term NSAID use, neuroleptics, spironolactone, Depo-Provera.
Male: anabolic steroids, chemotherapy.
what do you ask in then istory of someone who is infertile
o Female: Menstrual history, Previous pregnancies, Galactorrhoea (excessive/inappropriate production of milk), hirsutism Previous contraceptive history.
o Male: check for history of mumps orchitis,
Occupation: excess heat, radiation, toxic chemicals, sedentary (too much time/inactive) job, tight-fitting pants.
Abuse: of cigarettes, alcohol or substance
what do you look for in a physical examination of infertility
- Female: endocrine/systemic diseases/hirsutism, pelvic tumours, fibroids, cysts, genital abnormalities.
- Male: endocrine/systemic diseases, lack of virilisation, small testicular size, epididymal cysts.
describe how a semen analysis should be performed
- Should be performed after three days’ abstinence.
* To confirm abnormality, tests should be repeated 3 times, each after month’s interval.
what tests can be used for ovulation
Basal Body Temperature Chart
Pulsatile LH Secretion
when does LH peak
• Reaches a peak 36hrs before ovulating.
• Can be determined in urine using simple homing testing kits.
o Can be used to time sexual intercourse.
when must fertilisation occur
Fertilisation must occur 12-24 hours after ovulation (ovum only survives for 24 hours).
what confirms pregnancy in progesterone
Luteal Phase Plasma Progesterone Level
• If over >= 30 nmol/ml confirms.
what can test tubal potency and pelvic normality
• Assessed by ultrasonography, hysteroalpinography, hysteroscopy and/or laparoscopy/dye injection.
what does a Kremer test test for
Check for cervical hostility
what are the 3 phases of the menstural cycle
- Menstrual phase (day 1-5)
- Proliferative phase (day 6-14)
- secretory phase (day 15-28)
describe the three phases of the menstrual cycle
Menstrual phase (day 1-5): • Due to withdrawal of steroid support (oestrogen/progesterone) the endometrium collapses. • Endometrium is shed with blood from ruptured arteries (blood loss: 50-150ml).
Proliferative phase (day 6-14): • Oestrogen from mature follicle stimulates thickening of the endometrium. • Glands/spinal arteries form. • Oestrogen also causes the growth of progesterone receptors on endometrial cells.
Secretory phase (day 15-28): • Progesterone from corpus luteum: acts on endometrium. Enlargement of glands secret mucus and glycogen in preparation for implantation of fertilised oocyte. • No fertilisation = corpus luteum degenerates corpus albicans. Progesterone levels fall
what are the three phases of the ovarian cycle
- follicular phase - day 1 to 10
- ovulatory phase - days 11 to 14
- luteal phase days 15-18
describe the three phases of the ovarian cycle
Follicular phase: days 1 to 10
• 5-12 primordial follicles stimulated each month: one grows and matures.
• GnRH secreted from hypothalamus: stimulates anterior pituitary to secrete LH and FSH.
o These stimulates follicle to grow.
• Mature follicle secretes oestrogen.
o Inhibits further LH and FSH secretion by anterior pituitary (negative feedback).
o Stimulates growth of endometrium.
Ovulatory phase: days 11 to 14
• Negative feedback is temporary: oestrogen stimulates HPA resulting in burst of LH and FSH.
o Completion of meiosis I, onset of meiosis II in the oocyte.
Luteal phase: days 15 to 18
• Granulosa cells of mature follicle divide and form the corpus luteum
• Secretes progesterone and oestrogen. Prepares uterine endometrium for implantation
what does Prempak C do
Includes oestrogen and progesterone (combined hormonal replacement theraphy).
what is mandatory to do before treating subferitlity
(!) Before treatment it is mandatory to ensure women is immune to rubella infection.
• If rubella levels are low = immunize and advise against pregnancy for at least 3 months.
How do you treat ovulation therapy
- Treat using oral clomiphene citrate
* (If unsuccessful): human menopausal gonadotrophins.
how do you monitor treatment of ovulation therapy
(!) Monitoring of these include transvaginal ultrasound (observe follicular) and serum oestradiol measurements to reduce the risks of multiple pregnancy ovarian hyperstimulation syndrome.
NOTE: tubal microsurgery is advocated by some as first-line treatment for tubal subfertility.
• Other prefer in-vitro fertilisation.
what is IUI
Intrauterine Insemination (IUI)
how does IUI work
• Sperm is separated in lab, removal of slower speed sperm before partner is inseminated.
o Insemination takes place day 12-16.
o If using ovarian stimulating drugs: use ultrasound.
Who is IUI offered to
o People unable to have intercourse.
o Required specific consideration (HIV)
o Same sex relationships.
how long is IUI tried for
• Tried for 12 cycles before IVF.
who is IVF offered to
• Is offered to:
o Women under 40 who have no conceived after 2 years of unprotected intercourse.
Offer 3 full cycles.
o Women 40-42 offered one cycle if:
Never had IVF.
6 or more UII cycles.
No evidence of low ovarian reserve.
what is ovarian hyper stimulation syndrome
: Ovarian Hyper Stimulation Syndrome
• Consequence of drugs sued to stimulate ovarian function.
what is ICSI
• Single sperm injected directly into egg.
who is ICSI offered to
o Severe deficits in semen quality
o Obstructive and non-obstructive azoospermia.
o Failure of IVF treatment.
• Improves fertilisation rates vs IVF, but pregnancy rate is not better
what is post code variation
The situation with NHS funding for fertility treatment is very much a “treatment by
postcode” situation with PCTs in England making their own decisions on the level of
funding, if any, they put towards fertility treatment resulting in huge variations.
