Subfertility 1 Flashcards
What are important questions to ask women when taking a fertility history?
Menstrual history Previous pregnancies Contraception History of pelvic inflammation or abdominal surgery Drugs
What are important questions to ask men when taking a fertility history?
puberty prev fatherhood prev surgeries (hernias, orchidopelxy) illnesses drugs alcohol intake occupation (is he home at ovulation time) erectile problems
What are important questions to ask both men and women when taking a fertility history?
mood feelings about infertility technique frequency and timing of intercourse parenthood prev tests
What are the hormonal changes around early pregnancy?
low oestrogen levels stimulates FSH and LH release
FSH and LH initiate maturation of several follicles and an intermediate amount of oestrodiol
less FH and LH are produced
Development of mature follicle suppresses FSH
As follicle matures more oestradiol is produces and LH and FSH are released
Follicle ruptures releasing an oocyte, remaining becomes the corpus luteum
Corpus luteum releases oestrogen and progesterone to maintain endometrium
hCG produced by trophoblastic tissue acts on corpus luteum until 8-10 weeks gestation
What is primary infertility?
infertility without previous pregnancy or live birth
What is secondary infertility?
failure to conceive after 1 or more pregnancies (successful or not)
What are the different causes of infertility?
ovulation problems sperm quality problems blocked fallopian tubes unexplained infertility endometriosis other
in many couples there are multiple reasons
What are the different types of ovulation disorders?
type 1 - hypogonadal hypogonadism (rare)
type 2 - normogonadotrophic anovulation (usually PCOS)
type 3 - hypergonadotrophic hypogonadism
type 4 - hyperprolactinaemia
What is the most common cause of tubal disfunction?
infection - acute salpingitis causing occlusion of the fimbrial end with collections in tubal lumen
most likely caused by chlamydia
What other diseases cause tubal disfunction?
appendicitis, peritonitis, crohns or UC can causes peritubal adhesions and per-ovarian adhesions
any damage to internal structures of the tube can remove function
What uterine factors affect fertility?
distortion - submucous fibroids or congenital abnormalities make implantation less likely
adenomyosis linked to recurrent implantation failure
Intrauterine adhesions can affect implantation
How does endometriosis affect fertility?
severe disease - large ovarian cysts, extensive adhesions leads to subfertility
mild disease also linked to subfertility
surgical treatment can help
What are the cervical factors influencing fertility?
cervical infection or antisperm antibodies in cervical mucous or seminal plasma inhibit sperm penetration
What are the different ways in which infertility in females can be investigated?
menstrual history - if regular look at hormone level changes
transvaginal US of ovaries used to track follicle growth and diagnose PCOS or ovarian endometrioma
What should you measure in anovulation?
serum FSH, LH, oestradiol and AMH on day 2/3 of the menstrual cycle
serum prolactin
thyroid function
MRI or CT of sella turcica if prolactin released
How do you measure ovarian reserve?
AMH in serum to determine +/- antral follicle count with transvaginal USS
Low AMH or AFC suggests poor oocyte yield with IVF
Can’t identify quality of oocytes, usually linked to age
What investigations can be used to identify tubal patency?
hysterosalpingography - injection of contrast into uterus and fallopian tubes
Hysterosonocontrast sonography - use transvaginal USS for a real time filling
Laporoscopy and dye insufflation - direct visualisation, test tubal patency by injecting dye
What is the first line treatment of anovulation?
clomiphene citrate
produces ovulation in 80% of subjects and pregnancy in half of those
given on day 2-6 and monitor ovulation and monitor follicle growth on USS
What is the second line treatment for anovulation?
laporoscopic ovarian diathermy (LOD) ~70% induction of ovulation
drug free and lower risk of multiple pregnancy
How is tubal pathology treated?
IVF has replaced surgery almost completely
all surgery increases the risk of ectopics
What is intrauterine insemination?
soft catheter and low dose gonadotropin to stimulate ovulation
live birth rate 15-20% per cycle
more cost effective than IVF
good for coital dysfunction or cervical mucus abnormality
How does IVF and embryo transfer work?
stimulation of development of multiple ovarian follicles using gonadotrophins and GnRH agonists
collect oocytes using transvaginal USS guided needle aspiration
culture fertilised oocytes for up to 5 days, then best blastocytes are transferred to the uterine cavity
What is the main outcome determinant?
female age
increasing numbers will use donated oocytes from younger women
What are the major problems with IVF pregnancies?
multiple pregnancy
premature birth
What is ovarian hyperstimulation syndrome?
overdose with gonadotrophins - OHSS - excessive follicle development, high circulating oestrogen concerntrations and VEGF
potentially lethal
What are the consequences of severe ovarian hyperstimulation syndrome?
ovarian enlargement fluid shift and ascites pleural effusion sodium retention oliguria
may become hypovolaemic, hypotensive, can develop renal failure, ARDS and VTE
How is ovarian hyperstimulation syndrome managed?
mild can be managed conservatively
severe can give human albumin and drain fluid to decrease load
ACEIs may be indicated
