Reproduction: Infertility Flashcards
Infertility
Failure to achieve a clinical pregnancy after 12 months or more of regular unprotected intercourse (in absence of known reason) in a couple who have never had a child
Primary infertility
Couple never conceived
Secondary infertility
couple previously conceived but pregnancy not successful (e.g. miscarriage or ectopic pregnancy)
Epidemiology
Affects 1:6 couples (~15%)
Factors Increasing chance of conception
Women <30 years Previous pregnancy <3 years trying to conceive Intercourse occurring around ovulation Womens BMI 18.5-30 Caffeine intake <2 cups daily No use of recreational drugs
Infertility aetiology
Multiple factors (female +/- male)
Tubal factor Ovulatory dysfunction Diminished ovarian reserve Endometriosis Uterine factor Fibroids
Anovulatory Infertility
Ovaries do not release an oocyte during menstrual cycle
Anovulatory Infertility Aetiology
Physiological
- Before puberty
- Pregnancy
- Lactation
- Menopause
Gynaecological Conditions
- Hypothalamic (anorexia/ bulimia, excessive exercise)
- Pituitary (hypoprolactinaemia, tumours, Sheehan syndrome)
- Ovarian (PCOS, premature ovarian syndrome)
others
- systemic disorder
- endocrine disorder
- drugs
Polycystic Ovarian Syndrome
heterogeneous disorder characterised by hyperandrogegism and ovarian dysfunction which results in amenorrhoea or oligomenorrhoea and is associated with sub fertility.
PCOS prevalence
Commonest endocrine disorder in women
PCOS aetiology
Inherited condition
Weight gain exacerbates condition
PCOS clinical features
obesity
hirsutism or acne
cycle abnormalities
Infertility
PCOS endocrine features
High free androgens
High LH
Impaired glucose tolerance
PCOS diagnosis
Requires ⅔
Chronic an ovulation
Polycystic Ovaries
Hyperandrogenism
Premature Ovarian syndrome prevalence
1% before age 40
Premature Ovarian Syndrome Aetiology
Idiopathic Genetic - Turners Syndrome, Fragile X Chemotherapy Radiotherapy Oophorectomy
Premature Ovarian Syndrome clinical features
hot flushes
night sweats
atrophic vaginitis
Premature ovarian syndrome endocrine features
High FSH
High LH
Low oestradiol
Tubal Disease Aetiology
Infective
- Pelvic inflammatory disease
- transperitoneal spread
- procedures (IUCD insertion, hysteroscopy)
Non-infective
- Endometriosis
- Surgical
- fibroids
- Polyps
- Congenital
- Salpingitis Isthmica Nodosa
Tubal Disease Clinical Features
Abdo/pelvic pain Febrile Vaaginal Discharge Dyspareunia -Cervical excitation -Menorrhagia -Dysmenorrhoea -Infertility -Ectopic Pregnancy
Endometriosis
Presence of endometrial glands outside uterine cavity
Endometriosis prevalence
~20%
Endometriosis aetiology
–> Retrograde menstruation
Altered immune function
Abnormal cellular adhesion molecules
Genetic
Endometriosis Clinical Features
Dysmenorrhoea -Dysparenuia -Menorrhagia - Painful defection -Chronic pelvic pain Uterus may be fixed and retroverted
Scan may show characteristic ‘chocolate’ cysts on ovary
Male Infertility Pre-testicular aetiology
Endocrine
- hypogonadotrophic hypogonadism
- Hypothyroidism
- hyperprolactinaemia
- diabetes
Coital Disorders
- Erectile dysfunction
- ejaculatory failure
Male Infertility: Testicular Aetiology
Genetic
- Klinefelter syndrome
- Y chromosome deletion
- Immotile cilia syndrome
Congenital
- Cryptorchidism
- Infective
- Antispermatogenic agents
Vascular
- Torsion
- Varicocele
Immunological
male Infertility: Post testicular aetiology
OBSTRUCTIVE
Epididymal
- Congenital
- Infective
Vasal
- Genetic: CF
-Acquired
Vasectomy
Ejaculatory duct obstruction
Accessory Gland infection
- Immunological
Idiopathic
Post vasectomy
Non- Obstructive male Infertility clinical features
Low testicular volume
Reduced secondary sexual characteristics
Vas deferens preset
Non-obstructive male. infertility endocrine features
High LH and FSH
Low testosterone
Obstructive male Infertility clinical features
normal testicular volume
normal secondary sexual characteristics
Vas deferent may be absent
Obstructive male infertility endocrine features
Normal LH, FSH and testosterone
Investigations of infertility
History
Female Exam
Male exam
Investigation of female
Endocervical swab for chlamydia
Cervical smear if due
Blood for rubella immunity
Midluteal progesterone level
- progesterone >30nmol/L suggests ovulation
Tests of tubal latency
Hysterosalpingiogram
- If no known risk factors of tubal/ pelvic pathology
- If laparoscopy contraindicated due to obesity, previous pelvic surgery, Crohn’s
Lparoscopy
- Possible tubal /pelvic disease
- Known previous pthology
- History suggestive of pathology
- Previously abnormal HSG
Hysteroscopy Investigation of Infertility
Only performed in cases where known or suspected endometrial pathology
- uterine septum, adhesions, polyp
Pelvic US Investigation of Infertility
Perform when abnormality on pelvic exam
- enlarged uterus. adnexal mass
When required from other investigations
- possible polyp seen at HSG
Infertility Investigations (Female0
Anovulatory Cycles or Infrequent Periods
- Urine HSG
- Prolactin
- TSH
- Testosterone and SHBG
- LH,FSH and oestradiol
Hirsute
- Testosterone and SHBG
Amenorrhoea
- Endocrine profile
- Chromosome analysis
Investigation of Male Infertility
Semen Analysis
-Twice over 6 weeks apart
If abnormal semen analysis
- LH and FSH
- Testosterone
- Prolactin
- Thyroid function
Severely abnormal semen analysis
- endocrine profile
- chromosome analysis
- screen for CF
- Testicular biopsy
Abnormality on genitalia exam
-Scrotal US
Management: Lifestyle Advice
Stop smoking Reduce/ stop alcohol intake Achieve BMI 18.5 to 30 Stop recreational drugs Stop taking methadone Reduce caffeine intake (<2 cups daily)
Importance of healthy weight
Obesity causes increase of fertility problem and miscarriage weight
Decreases success of fertility
Also important for male problem as obesity can result in erectile dysfunction and ejaculatory problems
Management: Vitamin Supplements
Folic Acid
- 400 micrograms daily before pregnancy and during first 12 weeks
- 5 milligrams if either parent has neural tube defect, previous baby with neural tube defect or parent has diabetes
Vitamin D
- 10 micrograms of Vitamin D per day for pregnant and lactating women at increased risk of Vit D deficiency
Routine Investigations
Blood Rubella Immunity Chlamydia Ovulation (progesterone test) Tubal Patency Test Semen Analysis
Management Reproductive Surgery (2)
Primary surgical treatment for infertility
Surgery to enhance IVF outcome
Primary treatment for infertility
Pelvic Adhesions
Grade 2 or 3 Endometriosis
- Chocolate cyst in ovary
Tubal Block
Surgery to Enhance IVC outcome
Laparoscopy
Hysteroscopy
Salpingostomy
Operation performed to restore free passage through a blocked Fallopian tube
Blocked portion of the tube is removed surgically and continuity is restored.
Tubal Disease
Mild Tubal Disease
- Total surgery may be more effective than no treatment
Proximal Tubal Obsturction
- Selective Salpingostomy plus tubal catheterisation or hysteroscopic tubal cannulation
Hydrosalpinx
Accumulation of fluid in one of the Fallopian tubes due to inflammation and subsequent obstruction
Usually a result of pelvic infection
Hydrosalpinx Management
Laparoscopic Salpingectomy before IVF treatment
Laparoscopy Contraindications (ie Crohns) --> hysteroscopic tubal cannulation
Intrauterine Adhesions
Patients with amenorrhoea and intrauterine adhesions
–> hysteroscopic adhesiolysis
Hysteroscopic adhesiolysis is likely to restore menstruation and improve chance of pregnancy
Endometriotic Cyst
Minimal or mild endometriosis
- surgical ablation or resection + laparoscopic adhesiolysis
Ovarian Endometriomas
- laparoscopic cystectomy
Moderate/ Severe Endometriosis
- Surgical treatment
Measure or Polypectomy
Polypectomy
Endoscopic or surgical removal of a poly
Fibroid Management
Submucosal Fibroids
- Treat hysteroscopically
Intramural Fibroids
-Treatment individualised
Subserosal Fibroid
- Unlikely to have impact on fertility
Conservative treatment not routinely offered
Male Fertility Management
Surgery to obstructed vas deferent
intrauterine insemination in mild disease
Intracytoplasmic sperm infection (ICSI)
Surgical Sperm aspiration from epididymis or textile combined with ICSI
Donor Sperm Insemination
IVF Treatment (Stages-9)
Pre-IVF Workup Ovarian Stimulation Monitoring Ovulation Induction Oocyte Retrieval Preparation of Sperms In Vitro Fertilisation Embryo Transfer Luteal Support
