PBL 1: Subfertility Flashcards
Define subfertility
Inability to conceive for 12 months after commencing unprotected regular intercourse
What types of subfertility are there?
Primary
Secondary
What are causes of subfertility?
Pelvic inflammatory disease
Endometriosis
Fibroids
PCOS
What are the three types of ovulatory causes?
T1: Hypopituitary failure -> anorexia
T2: Hypopituitary dysfunction -> PCOS, hyperprolactinaemia
T3: Ovarian Failure
What is PSCOS characterised by?
Mild obesity
What is diagnostic criteria for PSCOS?
Oligomenorrhea
Clinical hyperandrogenaemia
Polycystic ovaries on ultrasound
What is cause of PSCOS?
Insulin resistance -> hyperinsulinaemia -> androgen production theca cells
What is management for PSCOS if patient wishes to conceive?
Weight loss
Clomiphene
Surgery: ovarian drilling or wedge resection
What is management of PSCOS if patient does not wish to conceive?
Low dose contraceptive pills (restore menstrual regulatory)
Metformin
Anti-androgens
What does ovarian failure involve?
Persistent FSH raised
What is management of ovarian failure
Donor eggs
Alternative parenting
What are the tubdal and uterine causes of infertility?
Pelvis inflammatory disease
Endometriosis
Fibroids
What is pelvis inflammatory disease
Severe inflammation of the peritoneal cavity caused by infection spreading from the vagina and cervix to the uterus, oviducts, ovaries and pelvis area
How to diagnose PElvis inflammatory disease?
May be asymptomatic
Pelvis pain, dyspareunia, fever
Cervical excitation (painful cervix when touched)
What are causes of pelvic infalmmatory disease?
STIs such as chlamydia
gonorrhoea
How to manage pelvic inflammatory disease?
Antibiotics
rest
abstinence
What is endometriosis?
Presence of tissue histologically like endometrium outside the uterine cavity
How to diagnose endometriosis?
Pain
Dysmenorrhoea
Menorrhagia
Dyspareunia
How to manage endometriosis?
NDAIDs
COPC
GnRH Agonists
Surgery
What are fibroids?
Benign tumours of smooth muscle of myometrium
NOTE THE LOCATION OF FIBROIDS
Symptoms of fibroids?
Heavy regular periods
Menorrhagia
Dyspareunia
How to treat fibroids?
COCP LARCs surgical Radiological (embolisation) Surgery (hysterectomy)
What are male factors?
Testicular Azoospermia Reversal of vasectomy Ejaculatory problems hypogonadism
What are coital problems
Dyspareunia
Coital frequency <3 times a week
What do you not offer in unexplained infertility?
Clomiphene as it does not increase chance of pregnancy/live birth
After how many years do you offer IV?
2 years
What drugs are linked to infertility in females?
Long-term NSAID use
neuroleptics
spironolactone
depo-provera
What drugs are linked to infertility in men?
Anabolic steroids
chemotherapy
What drugs are linked to both male and female infertility?
Chemotherapy
Illicit drugs
How do you diagnose infertility in female (history wise)?
Menstrual history previous pregnancies galactorrhoea hirutism previous contraceptive history
What do you check for history wise in males to diagnose?
history of mumps orchitis
occupation e.g. excessive heat
abuse e.g. alcohol
What do you examine for in female?
endocrine/systemic diseases hirsutism pelvis tumours fibroids cysts genital abnormalities
What do you examine for in males?
endocrine/systemic diseases
lack of virilisation
small testicular size
epididymal cysts
When do you perform semen analysis?
after 3 days of abstinence
to confirm abnormality, done 3 times. each after month’s interval
What other tests can be done?
Ovulation tests basal body temperature chart pulsatile LH secretion Luteal phase plasma progesterone level tubal patency + levic normality postcoital/kremer tests
How long must fertilisation occur after ovulation?
12-24 hours
What do you check for in postcoital/kremer test?
Cervical hostility
What do you check for in pulsatile LH secretion test?
Reach peak 36 hrs before ovulating
Determined in urine in simple homing testing kits
What will luteal phase plasma progesterone level be to confirm subfertility?
> =30nmol/ml
How does prempak-C mechanism of action work?
Includes oestrogen and progesterone
What is it vital to ensure before treatment of subfertility?
Woman is immune to rubella
How to treat ovulation failure?
Oral clomiphene citrate
if unsuccessful then use human menopausal gonadotrophins
What do you monitor in treatment of female?
Transvaginal ultrasound (observe follicular) Serum oestradiol measurements to reduce risks of multiple pregnancies (ovarian hyperstimulation syndrome)
What can be used 1st line for tubal subfertility?
Tubal microsurgery
What is intraterine insemination
Sperm is separated in lab and there is removal of slower speed sperm before partner is inseminated
When does insemination take place in IUI?
day 12-16
What do you use to monitor IUI if using ovarian stimulating drugs?
ultrasound
Who do you offer IUI to?
Ppl who can’t have intercourse
Required specific consideration (HIV)
Same sex relationships
How many trials do you use IUI for before IVF?
12 cycles
Who do you offer IVF to?
Women under40 who have not conceived after 2 yrs of unprotected intercourse
women 40-42 is never had IVF
What is intracytoplasmic sperm injection
Single sperm injected directly into egg
When is ICSI offered?
Severe deficits in sperm quality
Obstructive and non obstructive azoospermia
failure of IVF treatment
What is post–code variation?
NHs funding for fertility treatment is very different dependent on where a person lives as the trusts make their own decisions
