Sub/Infertility Flashcards
Define infertility
Failure to conceive despite regular unprotected intercourse
NICE - doesn’t specify
WHO - 1 yr
After how long should fertility be investigated for a couple trying to conceive?
In what special cases should investigations be done earlier?
1 yr
If the female is >35 yrs old Amenorrhoea Oligomenorrhoea Past PID Undescended testes Cancer treatments
Female Causes:
At what age does fertility steeply decline?
Late 30s
Also known as premature ovarian failure, happens when a woman’s ovaries stop working normally before she is 40.
Ovulatory causes:
1) HPO failure (hypogonadotropic hypogonadal)
- Psych disease leading to this
- Kallmann’s syndrome - what is it?
2) Normogonadotrophic normoestrogenic causes:
- PCOS is the main cause of this. How does this happen?
Anorexia + intense exercise
Congenital low GnRH and anosmia
Unclear mechanism, but there is evidence of arrested antral follicle development, which, in turn, may be caused by abnormal interaction of insulin and luteinizing hormone (LH) on granulosa cells.
Ovulatory causes:
3) Primary ovarian failure (hypergonadotropic hypoestrogenic):
- What type of menopause may happen?
- What type of cancer Rx could cause this? - 2
- What genetic disease could lead to this? - 2
- Another metabolic disease that causes infertility with not know the cause?
4) Hyperprolactinaemia - why does this inhibit GnRH release? What can cause this?
Premature menopause
Radiotherapy
Chemotherapy
Turners
Fragile X
Raised prolactin levels suppress oestrogen release, therefore, causing irregular or no ovulation.
Prolactin-secreting pituitary tumour.
Tubular Causes:
The most common cause?
What can cause adhesions? - 4
PID
Endometriosis
Appendicitis
IBD
Abdo surgery
Other uterine causes:
What submucosal tumour could lead to infertility?
What is ashermans syndrome?
Fibroids
An acquired uterine condition that occurs when scar tissue (adhesions) form inside the uterus and/or the cervix.
It is characterized by variable scarring inside the uterine cavity, where in many cases the front and back walls of the uterus stick to one another.
What might be wrong in the cervix which doesn’t allow sperm to cross?
Thick, dry, or sticky mucus is often caused by hormonal imbalances and frequently co-occurs with ovulation problems.
A thickened consistency directly interferes with sperm motility.
Some medication side effects can cause this.
Acidic mucus creates an environment hostile to sperm.
Male causes:
The most common unexplained reason?
Drugs:
- Why does alcohol affect sperm?
- Why do anabolic steroids affect sperm?
Genetic:
- Why are men with CF infertile?
Low sperm count which can’t be explained
Lowering testosterone levels, FSH, and LH, and raising oestrogen levels, which reduce sperm production. shrinking the testes, which can cause impotence or infertility. changing gonadotropin release which impacts sperm production.
Most men with CF (97-98 percent) are infertile because of a blockage or absence of the sperm canal, known as the congenital bilateral absence of the vas deferens (CBAVD).
The sperm never make it into the semen, making it impossible for them to reach and fertilize an egg through intercourse.
Male causes:
Infection:
- Mumps - why does this cause infertility?
- Chlamydia - why does this cause infertility?
When the disease gets bad, inflammation doesn’t confine itself to one gland. Inflammation of the pancreas can also happen.
And, for the post-pubescent, the virus can go for the endocrine glands – the mammary glands and the ovaries in women, and the testes in men.
Women can be rendered infertile by severe inflammation, but it’s rare.
Men who develop orchitis, inflammation of the testicles, are slightly more likely to be rendered infertile.
This does not happen to the majority of men infected with mumps, but it can happen.
Many men who get the mumps experience some negative fertility effects.
Dramatic genetic damage in sperm leading to male infertility
Male causes:
Anatomical:
- Varicocele - what is it?
- Why are undescended testes bad?
- Retrograde ejaculation - what is it?
An enlargement of the veins within the loose bag of skin that holds your testicles (scrotum).
A varicocele is similar to a varicose vein you might see in your leg.
Causes a lower sperm count and quality
—–
When semen enters the bladder instead of emerging through the penis during orgasm.
Although you still reach sexual climax, you might ejaculate very little or no semen.
This is sometimes called a dry orgasm. Retrograde ejaculation isn’t harmful, but it can cause male infertility.
Male causes:
Trauma and surgery:
- Why can inguinal hernia repair lead to this?
- What surgery is used to prevent sperm reaching semen?
What should you make sure you ask about that may be embarrassing?
Due to injury to the vas deferens
Vasectomy
Erectile dysfunction
History:
What should you ask the woman?
What should you ask the man?
What should you ask in regards to sex and relationships?
Gynae Hx
Groin surgery
Mumps
Alcohol
ED
Frequency
Timing
Mood
Technique
Examination:
What should be measured?
Why are swabs taken?
What is used to measure size of testes?
BMI
Chlamydia
Prader Orchidometer
MALE - Investigations:
Oligospermia:
- What is it?
- What can cause it?
Azoospermia:
- What is it?
- Non-obstructive cause?
- Obstructive causes?
Asthenozoospermia:
- What is it?
Not enough sperm
No sperm prod.
Chromosomal causes
Reduced sperm motility
MALE - Investigations:
Semen analysis - what is key to remember?
How long after should the sperm analysis be repeated if abnormal?
Endocrine:
- What does raised FSH suggest?
- What are LH and Testosterone used to find?
Chromosomal and genetic testing for what
It is still normal for > 90% of sperm to be abnormal
Testicular failure
Androgen deficiency
Excluding CF and other genetic diseases
FEMALE - Investigations:
It is important to establish whether she is ovulating. What signs would indicate she is ovulating?
Formal testing:
- Mid-luteal progesterone is measured. How many days before their period is it measured? What does raised P suggest? What if their cycle is irregular?
- FSH - what suggests ovarian failure?
- LH/FSH - what does this being raised suggest?
If cycles are regular and she has midcycle symptoms (fever, abdo pain)
7 days before period
Indicates ovulation
P is checked every 2-3 days
Raised FSH
PCOS
Menopause
FEMALE - Investigations:
Further endocrine testing:
- What hormone is measured for PCOS?
- Why is prolactin measured?
TVUS:
- What indicates PCOS?
- What indicates endometriosis?
- What indicates fibroids?
- What indicates uterine polyps?
Testosterone
Polycystic ovaries
Lesions and adhesions on pelvic structures
Masses around uterus
Can see on scan - may also be causing IMB, PCB or PMB
FEMALE - Investigations:
Further tests for tubal disease:
- How is chlamydia investigated?
- What type of imaging can be used to look for tubular disease? - 2
Vaginal swab + PCR
Hysterosalpingogram contrast XR (HSG) or laparoscopy + dye (gold standard but invasive)
Management - Primary Care:
Advise for any couple concerned about fertility:
- How often should they be having sex?
- What should they stop doing - lifestyle?
- Under what BMI should they get to? What does a lower BMI also increase the chances of success in?
- What should be prescribed before pregnancy?
- What virus should be tested for and provided immunisation for due to its adverse effects on a foetus?
- What should be checked to make sure it ts up to date?
Sex every 2-3 days
Stop smoking
BMI < 30
Increases chances of IVF success
Also helps sperm count
Folic acid
Rubella virus
Smears
Management - Primary Care:
After 1 yr of trying, offer formal assessment, starting with what:
- What should be tested in both sexes?
Indications for an earlier referral?
Bloods to check for ovulation in women.
Semen analysis in men.
Features of an underlying cause of infertility:
- Dysmenorrhoea
- Pani
- PMH of gynae problems
Female >35 yrs and trying for 6 months
Management - Secondary Care - FEMALE:
What lifestyle change should be done?
What medication is used to stimulate ovulation as the first line?
What laparoscopic surgery is done for patients with PCOS?
What drug can be given to induce ovulation which is only prescribed by a specialist fertility unit?
Tubal disease:
- What fertility Rx can be done that won’t involve ovulation near the ovaries?
- What can be done for endometriosis?
Weight loss/gain
Clomifene citrate
Laparoscopic ovarian drilling
IVF
Resect or ablate any endometriosis
Management - Secondary Care - MALE:
What multivitamins can be prescribed?
What is ICSI which is the main tool for most male infertility? Why is it used?
What can be done for obstructive azoospermia?
Vit C
Zinc
Selenium
Intracytoplasmic sperm injection - Sperm injected directly into the egg
Surgical correction of epididymal blockage - 1st line
Sperm retrieval from testes/epididymis - 2nd line
Unexplained fertility:
How is this defined?
Options for this:
- IVF - what does it stand for?
- IUI - what does it stand for?
IUI - this is a good alternative for people who can’t have sex. Give some examples of this?
Unable to conceive after 2 yrs of trying, despite normal investigations
In-vitro fertilisation
Intrauterine insemination ----- Disabled ED Same-sex couples
