Subfertility Flashcards
What is subfertility?
a woman of reproductive age that has not conceived after 1 year of regular, unprotected sexual intercourse
o Chances of getting pregnant 19-26yo = 98% over 24 months (twice weekly unprotected sexual intercourse)
o Sub-fertility affects 1 in 6 couples (incidence increases with maternal age)
Who’s to blame for subfertility?
o Female problem = 30-40%
o Unexplained = 30%
o Male problem = 25-30%
What are the S/S of subfertility in Group 1 ovulatory disorders women?
Hypothalamic-pituitary failure (hypogonadotropic hypogonadism)
o Low gonadotrophins and low oestrogen
o Low weight, excessive exercise, Kallman’s syndrome, Sheehan’s syndrome
What are the S/S of subfertility in Group 2 ovulatory disorders women?
Hypothalamic-pituitary-ovarian dysfunction (normogonadotrophic normogonadism)
o Normal gonadotrophins, normal oestrogen
o PCOS
What are the S/S of subfertility in Group 3 ovulatory disorders women?
Ovarian Failure (hypergonadotrophic hypogonadism)
o High gonadotrophins, low oestrogen
o POI (amenorrhoea of 4 months, <40yo, FSH high on 2 consecutive tests
What are the causes of subfertility in men?
Structural (cryptorchidism, absence of vas deferens in CF, varicocele)
Hypothalamic/Pituitary (hypothalamic hypogonadism, hyperprolactinaemia)
Infectious (epididymitis, mumps orchitis)
Pharmacological (recreational drugs)
Functional (erectile dysfunction)
Lifestyle (ETOH, smoking, BMI >30)
Alcohol?
Genetic (Klinefelter’s XXY, Kallman’s, testicular feminisation)
What are the S/S of subfertility in Group 4 ovulatory disorders women?
Prolactinaemia, Thyroid Disease
o Prolactinoma, primary hypothyroidism, chronic renal failure, drugs
What are the non ovulatory disorder related S/S of subfertility?
- Tube Disorders
- Cervico-uterine issues
- Chromosomal/ Genetic
- Functional
§ Tubal disorders (block (infections, adhesions, endometriosis), congenital, salpingectomy)
§ Cervical and uterine factors (uterine abnormalities, fibroids)
§ Genetic / developmental (chromosomal abnormalities (Turner’s), or genetic issues (CF))
§ Lifestyle / functional (smoking, method of sex)
What Ix do you do for subfertility?
o 1st line basic tests (men and women):
§ Male:
· Semen analysis (2 tests, 3m apart) – if azoospermia, most commonly due to varicocele
· Chlamydia screen
§ Female:
· Mid-luteal (day 21) progesterone (confirm ovulation) -> >30 indicated ovulation
o Adjust if cycle >28 days
o If POI, you cannot do this as there are no periods to base the measurement off
· Chlamydia screen
· Other -> prolactin, TFTs, progesterone (prolonged irregular cycles), LH/FSH (irregular cycles)
o Ovarian reserve measure (≥1 of 3 results measures around day 3 of the cycle):
§ FSH -> raised; inaccurate during the luteal phase (being supressed by progesterone)
§ Anti-Mullerian hormone (AMH) -> low; does not change with cycles so taken anytime
§ TVUSS -> Antral Follicle Count (AFC: <4 = poor response; 16+ = good response)
o Tubal assessment:
§ No co-morbidities -> hysterosalpingography / HSG -> assess patency
§ Co-morbidities (hx of PID, ectopics, endometriosis) -> laparoscopy and dye
What do you say in PACES counselling for subfertility?
o Risk Factors: advanced maternal age, smoking and alcohol use, obesity, irregular periods, STI
o Explain that there is still a chance of getting pregnant naturally (15% of couples fail to conceive after 1 year)
o Explain that you would like to start investigations (blood test looking at hormone levels, USS looking at structure of the uterus and follicle count and HSG if there are risk factors)
o Encourage regular unprotected sex at least every other day (not too much -> let sperm count recover)
o Discuss management options depending on likely cause of subfertility
What are the complications of subfertility?
o Ovulation induction (from multiple eggs in multiple pregnancy)
o Ovarian Hyperstimulation Syndrome (ovaries become hyperstimulated -> exposure to hCG pro-inflammatory mediators à ovarian enlargement, increased vascular permeability (third spacing), prothrombotic state)
§ S/S: abdominal pain + distension, N+V, SOB, oedema/ascites
§ Management: Symptomatic management, fluid replacement, VTE prophylaxis
What is the management of subfertility?
o 1st line: wait for regular intercourse to be established for at least 12 months (every 2-3 days)
§ Key Information: BMI 20-25, folic acid, regular intercourse (every 2-3 days), smoking/drinking advice
§ Ix -> perform investigations after 12 months…
o 2nd line: unexplained sub-fertility, mild endometriosis, or ‘male factor’ sub-fertility -> try for another 12m, After this, you can consider IVF
o Medical management for fertility:
§ Ovulation induction -> anovulation (PCOS, idiopathic):
· 1st line: clomiphene (blocks oestrogen-R -> increased LH/FSH release)
· 2nd line: FSH and LH injections
· 3rd line: pulsatile GnRH or DA agonists
What is assisted conception?
o Assisted conception:
§ Intrauterine insemination ± LH/FSH -> idiopathic, anovulation unresponsive to OI, mild male factor, minimal to mild endometriosis (sperm placed in uterus with fine plastic tube at time of ovulation)
§ IVF -> blocked tubes, male minor factor, idiopathic, unsuccessful OI or intrauterine insemination
· Leave the egg and sperm in a petri dish and they fertilise each other
· Availability is decided trust-by-trust (i.e. a postcode lottery) – NICE guidance:
· Most common treatment for male infertility
· Sperm directly injected into the egg (bypass natural barriers)
§ Donor insemination ± LH/FSH -> azoospermia, single women, same sex couples, infectious disease
§ Donor egg with IVF -> POI, bilateral oophorectomy, gonadal dysgenesis, high-risk generic disorder
What is the surgical management of fertility?
§ Operative laparoscopy -> adhesions, ovarian cyst, endometriosis
§ Myomectomy -> fibroids
§ Tubal surgery -> blocked tubes amenable to repair
§ Laparoscopic ovarian drilling -> PCOS (unresponsive to medical management)
· Removes endometrium -> reduce amount of androgen-producing tissue
Who gets IVF?
o Women <40 offered 3 cycles of IVF if…
§ Subfertility for 2 years
§ Not pregnant after 12 cycles of artificial/intrauterine insemination
o Women 40-42 offered 1 cycle of IVF if…
§ Subfertility for 2 years and/or not pregnant after 12 cycles of AI
§ Never had IVF
§ No evidence of low ovarian reserve
§ Informed about additional implications of IVF at this age
§ Intracytoplasmic sperm injection (ICSI) -> oligospermia, poor fertilisation (DM, erectile dysfunction)
