Subfertility

Question 1

Define Subfertility?

Answer 1

A woman at reproductive age that has not concieved after 1y of regular unprotected sexual intercourse

between 19-26 - 98% of getting preg over 24months
subfertility can affect 1/6 couples

30-40% female
30% unexplained
25-30% males

Question 2

Causes and Rf of female subfertility

Answer 2

Female causes

Ovulatory disorders (4 groups)
Group 1 - hypothalamic failure= low GnRH and oestrogen (low eeight, excessive exercise, kallmans syndrome, sheehans)
Group 2- hypothal-pit-ovarian dys (normal GnRH, LH/FSH, oestrogen ( PCOS)
Group 3- ovarian failure- High LH/FSH, Low oestrogen (premature ovarian failure (ammenrorhea 4m, over 40, FSH high 2x)
Group 4- prolactinoma, thyroid disease ( Prolactinoma, hypothyroidism, renal failure, drugs)

Tubal disorders (infection, adhesions, endometriosis)
Cervical and uterine factors ( fibroids)
Genetic (Turners, Genetic (CF)
Lifestyle (smoking, method of sex)

Question 3

Cause and Rf of Male subfertility

Answer 3

Structural - (cryptochridism, variocele)
Hypothalamic ( prolactinoma, hypothalamic hypogonadism)
Functional (erectile dysf)
Pharmacological (recreational drugs, Drugs)
Infection - Epiddidymitis, mumps orchitis)
Lifestyle (ETOH, Smoking, BMI)
Genetic - Kleinfelters, Kallmans, CF)

Question 4

Ix of subfertility

Answer 4

Need a good Hx - coital frequency, method, menstrual frequency, PCOS sx, Conctraceptive, STI, PMH, DHx, Shx
1y of trying

1st line basic-
Male - semen analysis (2 test, 3m apart)- if NO sperm- commonly variocele
Chalmydia screen

Female - Mid luteal progestorone (confirms progestorone (adjust if cycle over 28d)- POI cant do that
chlamydia, prolactin, TFT, LH/FSH

2nd line -
ovarian reserve measure - FSH not ideal, anti-mullerian hormone - low, not change with cycle so fine
TVUSS= antral follicule count (4 is bad, <16 is good)

Tubublar assessment-
Hysterosalpingography
or lapscopy and dye

Question 5

Mx of subfertility

Answer 5

1st line - wait for an ESTABLISHED 12m with regular sex
2nd- try and manage as mild endometriosis, investiate men, etc

Medical mx -
Ovulation induction if anolvuation (PCOS, Idiopathic) -Clominophene,
2ndline FSH
3rd - GNRH/ Dopamine agonst

Surgerical-
laproscopy for adhesions, cyst, endometriosis
myomectomy fibroidds
tubal surgery- for blocked tubes
Laproscopic ovarial drilling -PCOS

Assisted contraception (see other card for details)
Intrauterine issemination + LH/FSH

IVF
Intracytoplassmic sperm injection

Donor insemination
donor egg + IVF

Question 6

What are the different form of assisted contraception available

Answer 6

Intrauterine isemination + LH/FSH - for idipathic, anovulation responding to therapy, mild endometriosis, mild male factor

IVF - blocked tube, male factors, idiopathic, anovulation not responding
(leave egg + sperm in petri dish so fertilise)
availability is trust by trsut - <40 offered 2 cycles
40-42 offered 1 cycle (but even that hard- no prior, no low ovarian reserve etc)

Intracytoplasmic sperm infection (male factors-functional)-
most common Mx of MALE factors

Donor iseminaition ( azoospermia, single women, seae sex)

Donor egg - POI, Oophrectome, risk of genetic disorders

Ovulation induction and IVF can cause multipregnancies
also care of ovarian hyperstimuation syndrome causing bleeding