SUBFERTILITY Flashcards
What percentage of couple trying to conceive will do so over the course of 1 year?
84%
What percentage of couple trying to conceive will do so over the course of 2 years?
92%
What is the definition of infertility?
Failure to conceive after regular unprotected sexual intercourse for 2 years
What is the difference between primary and secondary subfertility?
Primary refers to couple who have never had a previous pregnancy, whereas secondary refers to those who have had a previous pregnancy.
At what point do we investigate couples who are having trouble conceiving?
After 1 year of trying.
Investigation may be needed earlier if history reveals risk factors such as infection, menstrual irregularities or where female is over 35 years old
In what percentage of couples struggling to conceive will the factor be only from the male?
22%
In what percentage of couples struggling to conceive will the factor be only from the female?
57%
In what percentage of couples struggling to conceive will the factor be only from both the male and the female?
21%
What is considered frequent enough sexual intercourse in order to have a good chance of conceiving?
Every 2-3 days
What key things should be asked about in a history from a women in a subfertile couple?
Duration of subfertility
Frequency of intercourse
Coital problems - female vaginismus, dyspareunia
Previous pregnancies, outcomes and modes of delivery, including ectopic.
Past gynae history - menorrhagia (fibroids), dysmenorrhoea (endometriosis), Asherman’s (adhesions), previous infections, oligo/ameno-rrhoea
Past medical history - chronic (renal/thyroid), eating disorders
Drug history - previous contraceptive use, regular use of NSAIDs, folic acid supplements
Social - smoking and alcohol, exercise and weight loss
What are the female causes of infertility relating to ovulatory dysfunction?
Chronic systemic illness
Eating disorders
Obesity
PCOS
Hyperprolactinaemia
Hypo/hyperthyroidism
Cannabis use
NSAIDs
What are the female causes of infertility relating to tubal anomalies?
Pelvic inflammatory disease
Previous surgery
Previous ectopic pregnancy
Endometriosis
What are the female causes of infertility relating to problems with the uterus?
Fibroids
Uterine septae
Congenital anomaly
Asherman’s syndrome
What are the female causes of infertility relating to coital dysfunction?
Vaginismus
Dyspareunia
What key things should be asked in a history from a man in a subfertile couple?
Erectile/ejaculatory dysfunction
Past surgical history - inguinal hernia repair, undescended testes, testicular torsion, bladder neck surgery
Past medical history - cystic fibrosis (vas deferens obstruction), epididymo-orchitis (from STI), post-pubertal mumps (orchitis), chronic medical conditions (eg renal and diabetes)
Drug history
Social history - smoking, alcohol, occupational history (driving raises temp)
What drugs can lead to male subfertility?
Anabolic steroids Cannabis Cocaine Sulfasalazine (IBD) Colchicine (gout) Nitrofurantoin (Abx) Tetracycline (Abx) Alpha blockers - interere with ejaculation Beta blockers
What basic blood test is a first line investigation and should be done for a woman who presents as part of a subfertile couple?
Mid-luteal phase progesterone: performed a week before next period is due (normally day 21)
What investigations should be done for a woman who presents as part of a subfertile couple?
MId-luteal phase progesterone
Pelvic ultrasound - structural abnormalities of uterus, ovarian cysts (PCOS), hydrosalpinx
Microbiology - screen for chlamydia
Hysterosalpingogram (HSG) or Hysterosalpingo contrast sonography (HyCoSy) - testing tubal patency
Dye guided laparoscopy can be used to find tubal occlusion (semen screen must have been done before this invasive procedure)
What investigations should be done for a man who presents as part of a subfertile couple?
Microbiology - screen for chlamydia
Semen analysis
What are the normal parameters in semen analysis?
Volume - 1.5-5 mls
Count - more than 20 million/ml
Progression - more than 50%
Normal forms - more than 30%
How should a man go about providing a semen sample for analysis?
3 days abstinence with at least a 72 hour history of good health
Sample should be examined within 1 hour of production.
Ideally two samples should be taken at least 12 hours apart
What about a semen analysis would suggest epididymo-orchitis?
Presence of more than 106 WBC
What do we define oligozoospermia as?
Less than 15 million/ml count
What do we define asthenozoospermia as?
Less than 32% motility
What do we define teratozoospermia as?
Less than 4%
What is the most common cause of male subfertility?
Oligo-terato-asthenospermia
How do you treat a woman who is subfertile due to anovulation?
Optimise general health - thyroid disease, diabetes
Weight loss if high BMI
Consider clomiphene (anti-oestrogen) to induce ovulation
Consider adding metformin if overweight
Consider ovarian drilling
What are the most important risks associated with clomiphene use?
Ovarian cancer
Multiple prenancy
How do you treat a woman who is subfertile due to uterine, tubal or pelvic problems?
Often removed prior to IVF
Hydrosalpinges are drained
Endometriosis can be operated on
Tubal blockage can be surgically removed
What is first line in the treatment of male factor infertility?
Intrauterine insemination (IUI)
How many cycles of intrauterine insemination should be tried before IVF?
Up to 6
What is in vitro fertilisation (IVF)?
Process of harvesting eggs and incubating them with sperm for 2-3 days. Subsequent fertilised embryo is transferred into the female.
What are the steps of IVF?
- Down regulation of women’s own hormones using GnRH agonists - leads to reduced oestrogen production.
- Induction of multiple follicular development using gonadotrophins such as human menopausal gonadotrophin (hMG) which contains FSH and LH, and hCG (from urine of pregnant women)
- Egg collection - transvaginal guided by US, under sedation
- Sperm preparation
- In vitro fertilisation for 2-3 days
- Transfer of embryo
What is pre-implantation genetic diagnosis?
Technique whereby couples affected by hereditary disorder can screen embryos to see which may be affected.
What is intracytoplasmic sperm injection (ICSI)?
Advanced form of IVF where one sperm is directly injected into the egg. This has revolutionised treatment for those with very low sperm counts.
What are the risks of assisted reproductive techniques such as IVF and ICSI?
Multiple pregnancy
Low birth weight
ICSI shows higher risks of baby born with congenital malformations especially affecting urogenital system.
Ovarian hyperstimulation syndrome
What is ovarian hyperstimulation syndrome?
Systemic disease caused by ovulation induction where levels of oestrogen are too high. As a result there is increased vascular permeability. Fluid therefore accumulates in the third space (abdomen, chest) and leads to intravascular depletion.
What are the clinical features of ovarian hyperstimulation syndrome?
If mild then just some abdominal discomfort
If more severe, then nausea, vomiting, painful abdominal distension, ascites and pleural effusions.
What are the risks and complications of ovarian hyperstimulation syndrome?
Hepatorenal failure
Adult respiratory distress syndrome (ARDS)
VTE
How do we treat patients who suffer from an episode of ovarian hyperstimulation syndrome?
Admit
Careful fluid balancing
Thromboprophylaxis
Therapeutic drainage of accumulated fluid
How can you reduce the likelihood of ovarian hyperstimulation syndrome during ovulation induction?
Ultrasound monitoring of patients undergoing procedure. May be necessary to abandon cycle if too many follicles have developed to prevent OHSS.
What is the most important prognostic factor in the success rate of IVF?
Maternal age
What are the chances of IVF being successful in a woman of between 23 and 35 years?
20%
What are the chances of IVF being successful in a woman of over 40 years old?
6%
