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Reproduction: Infertility Flashcards

1
Q

Infertility

A

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

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2
Q

Primary infertility

A

Couple never conceived

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3
Q

Secondary infertility

A

couple previously conceived but pregnancy not successful (e.g. miscarriage or ectopic pregnancy)

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4
Q

Epidemiology

A

Affects 1:6 couples (~15%)

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5
Q

Factors Increasing chance of conception

A 
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
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6
Q

Infertility aetiology

A

Multiple factors (female +/- male)

Tubal factor 
Ovulatory dysfunction 
Diminished ovarian reserve
Endometriosis 
Uterine factor 
Fibroids
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7
Q

Anovulatory Infertility

A

Ovaries do not release an oocyte during menstrual cycle

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8
Q

Anovulatory Infertility Aetiology

A

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
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9
Q

Polycystic Ovarian Syndrome

A

heterogeneous disorder characterised by hyperandrogegism and ovarian dysfunction which results in amenorrhoea or oligomenorrhoea and is associated with sub fertility.

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10
Q

PCOS prevalence

A

Commonest endocrine disorder in women

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11
Q

PCOS aetiology

A

Inherited condition

Weight gain exacerbates condition

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12
Q

PCOS clinical features

A

obesity
hirsutism or acne
cycle abnormalities
Infertility

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13
Q

PCOS endocrine features

A

High free androgens
High LH
Impaired glucose tolerance

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14
Q

PCOS diagnosis

A

Requires ⅔
Chronic an ovulation
Polycystic Ovaries
Hyperandrogenism

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15
Q

Premature Ovarian syndrome prevalence

A

1% before age 40

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16
Q

Premature Ovarian Syndrome Aetiology

A 
Idiopathic 
Genetic 
- Turners Syndrome, Fragile X
Chemotherapy
Radiotherapy 
Oophorectomy
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17
Q

Premature Ovarian Syndrome clinical features

A

hot flushes
night sweats
atrophic vaginitis

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18
Q

Premature ovarian syndrome endocrine features

A

High FSH
High LH
Low oestradiol

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19
Q

Tubal Disease Aetiology

A

Infective

  • Pelvic inflammatory disease
  • transperitoneal spread
  • procedures (IUCD insertion, hysteroscopy)

Non-infective

  • Endometriosis
  • Surgical
  • fibroids
  • Polyps
  • Congenital
  • Salpingitis Isthmica Nodosa
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20
Q

Tubal Disease Clinical Features

A 
Abdo/pelvic pain 
Febrile
Vaaginal Discharge
Dyspareunia
-Cervical excitation 
-Menorrhagia
-Dysmenorrhoea
-Infertility
-Ectopic Pregnancy
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21
Q

Endometriosis

A

Presence of endometrial glands outside uterine cavity

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22
Q

Endometriosis prevalence

A

~20%

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23
Q

Endometriosis aetiology

A

–> Retrograde menstruation

Altered immune function
Abnormal cellular adhesion molecules
Genetic

24
Q

Endometriosis Clinical Features

A 
Dysmenorrhoea
-Dysparenuia 
-Menorrhagia 
- Painful defection 
-Chronic pelvic pain 
Uterus may be fixed and retroverted

Scan may show characteristic ‘chocolate’ cysts on ovary

25
Male Infertility Pre-testicular aetiology
Endocrine - hypogonadotrophic hypogonadism - Hypothyroidism - hyperprolactinaemia - diabetes Coital Disorders - Erectile dysfunction - ejaculatory failure
26
Male Infertility: Testicular Aetiology
Genetic - Klinefelter syndrome - Y chromosome deletion - Immotile cilia syndrome Congenital - Cryptorchidism - Infective - Antispermatogenic agents Vascular - Torsion - Varicocele Immunological
27
male Infertility: Post testicular aetiology
OBSTRUCTIVE Epididymal - Congenital - Infective ``` Vasal - Genetic: CF -Acquired Vasectomy Ejaculatory duct obstruction Accessory Gland infection - Immunological Idiopathic Post vasectomy ```
28
Non- Obstructive male Infertility clinical features
Low testicular volume Reduced secondary sexual characteristics Vas deferens preset
29
Non-obstructive male. infertility endocrine features
High LH and FSH | Low testosterone
30
Obstructive male Infertility clinical features
normal testicular volume normal secondary sexual characteristics Vas deferent may be absent
31
Obstructive male infertility endocrine features
Normal LH, FSH and testosterone
32
Investigations of infertility
History Female Exam Male exam
33
Investigation of female
Endocervical swab for chlamydia Cervical smear if due Blood for rubella immunity Midluteal progesterone level - progesterone >30nmol/L suggests ovulation
34
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
35
Hysteroscopy Investigation of Infertility
Only performed in cases where known or suspected endometrial pathology - uterine septum, adhesions, polyp
36
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
37
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
38
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
39
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) ```
40
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
41
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
42
Routine Investigations
``` Blood Rubella Immunity Chlamydia Ovulation (progesterone test) Tubal Patency Test Semen Analysis ```
43
Management Reproductive Surgery (2)
Primary surgical treatment for infertility Surgery to enhance IVF outcome
44
Primary treatment for infertility
Pelvic Adhesions Grade 2 or 3 Endometriosis - Chocolate cyst in ovary Tubal Block
45
Surgery to Enhance IVC outcome
Laparoscopy | Hysteroscopy
46
Salpingostomy
Operation performed to restore free passage through a blocked Fallopian tube Blocked portion of the tube is removed surgically and continuity is restored.
47
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
48
Hydrosalpinx
Accumulation of fluid in one of the Fallopian tubes due to inflammation and subsequent obstruction Usually a result of pelvic infection
49
Hydrosalpinx Management
Laparoscopic Salpingectomy before IVF treatment ``` Laparoscopy Contraindications (ie Crohns) --> hysteroscopic tubal cannulation ```
50
Intrauterine Adhesions
Patients with amenorrhoea and intrauterine adhesions --> hysteroscopic adhesiolysis Hysteroscopic adhesiolysis is likely to restore menstruation and improve chance of pregnancy
51
Endometriotic Cyst
Minimal or mild endometriosis - surgical ablation or resection + laparoscopic adhesiolysis Ovarian Endometriomas - laparoscopic cystectomy Moderate/ Severe Endometriosis - Surgical treatment Measure or Polypectomy
52
Polypectomy
Endoscopic or surgical removal of a poly
53
Fibroid Management
Submucosal Fibroids - Treat hysteroscopically Intramural Fibroids -Treatment individualised Subserosal Fibroid - Unlikely to have impact on fertility Conservative treatment not routinely offered
54
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
55
IVF Treatment (Stages-9)
``` Pre-IVF Workup Ovarian Stimulation Monitoring Ovulation Induction Oocyte Retrieval Preparation of Sperms In Vitro Fertilisation Embryo Transfer Luteal Support ```

Endocrine (25 decks)

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