Subfertility Flashcards
How is sub-fertility defined?
Woman of reproductive age who has not conceived after 1y of regular, unprotected sexual intercourse
Recall the groups of ovulatory disorders that may contribute to sub-fertility
Group 1: hypothalamic-pituitary failure (hypogonadotrophic hypogonadism, low weight/ excess exercise, Kallman’s, Sheehan’s)
Group 2: Hypothalamic-pituitary-ovarian dysfunction (PCOS, hyperprolactinaemia)
Group 3: Ovarian failure (POI)
What hormone levels are seen in each type of ovulatory disorder?
Hypothalamic-pituitary failure: Low LH, low FSH, low oestrogen
Hypothalamic-pituitary-ovarian dysfunction: normal LH + FSH + oestrogen
Ovarian failure: high LH + FSH, low oestrogen
Other than ovulatory disorders, what can cause sub-fertility in the female?
Tubal disorders
Cervical/ uterine (eg fibroids)
Genetic/ developmental (Turner’s/ CF)
Lifestyle/ functional (smoking, method of sex)
Recall 3 structural causes of infertility in men
Cryptochordism
CF- absence of vas deferens
Varicocele
Give 1 genetic cause of infertility in men
Klinefelter’s XXY
Give 2 infectious causes of infertility in men
Epididymitis
Mumps orchitis
How should a semen sample be collected?
Analysis should be performed after min 2 days + max 7 days abstinence.
Sample needs to be delivered to the lab within 1h
What should be included in the history when investigating sub-fertility?
Duration and type of infertility
Coital frequency
Menstrual hx
PCOS Sx
Contraceptive hx
Previous STI
PSHx
DHx
SHx (EtOH + smoking)
What should be looked for on examination in a female with sub-fertility?
BMI, Hirsuitism, Acne (PCOS)
Galactorrhoea (hyperprolactinaemia)
Syndromic features (Turners)
PV: Vaginismus (sexual difficulty)
Bimanua: cervical motion tenderness (PID), abdo mass (Fibroids)
What are the first-line basic tests to do in men and women to investigate sub-fertility?
Men: semen analysis (2 tests, 3m apart) + chlamydia screen
Women:
Day 21 progesterone (>30 indicates ovulation has occurred)
Chlamydia screen
FSH, LH, Oestradiol
Ovarian reserve tests
If irregular menstrual cycle: Prolactin, TFTs, testosterone
What are the Ovarian Reserve Tests?
FSH at Day 3 (to find basal level)
Anti-Mullerian hormone (AMH)
Antral follicle count (using TVUSS)
When is a tubal assessment performed? How?
After referral to secondary care
If no other comorbidities: hysterosalpingography (HSG) to assess patency
If comorbidities (eg hx of PID/ ectopics/ endometriosis) → laparoscopy + dye
What is the initial management for sub fertility?
Treat underlying cause e.g Weight loss for overweight PCOS
Sex every 2-3d
Folic acid
Smoking cessation + reduce EtOH
Healthy BMI 19-25
When should investigations be performed for sub-fertility?
Start Ix if not conceived after 1 y of regular (every 2–3 d) UPSI
Offer Ix earlier than 1y if identified as less likely to conceive
When should referral be made for sub-fertility? (Give 4 examples)
If Ix normal + no conception after 1y of UPSI
> 36y
Oligoamennhorea/ amennhorea
Prior Tx for cancer
What is the medical management for Group 1 (hypothalamic/ pituitary) sub-fertility?
Reverse cause e.g. gain weight, reduce exercise
Pulsatile GnRH/ directly replace gonadotropins
What is the medical management for Group 2 (HPO dysfunction) sub-fertility?
Weight loss + metformin
Clomifene to induce ovulation (SERM → increased GnRH release- if fails can try gonadotropins)
Dopamine agonists for hyperprolactinaemia
How can anovulation be managed in PCOS?
Ovulation induction:
1st line: clompihene (blocks oestrogen receptor to increase LH/FSH release)
2nd line: FSH/LH injections
3rd line: Pulsatille GnRH or DA agonists
Which causes of sub-fertility can be managed surgically?
Proximal tubal obstruction: Tubal microsurgery (catheterisation or cannulation)
PCOS: Laparoscopic ovarian drilling
Endometriosis: surgical ablation/ resection + laparoscopic adhesiolysis
Fibroids: Myomectomy
Obstructive azoospermia: surgical correction of epididymal blockage to restore patency
When can surgical correction not be used for male infertility?
In CF
“can’t repair what wasn’t there”
Recall the 5 options for assisted conception
Intrauterine insemination +/- LH/FSH
IVF
Intracytoplasmic sperm injection
Donor insemination +/- LH/FSH
Donor egg with IVF
How is IVF performed?
Leave egg + sperm in a petri dish + they fertilise each other
What is NICE guidance for availability of IVF?
Women <40 offered 3 cycles of IVF if
1. Subfertile for 2y
2. Not pregnant after 12 cycles of artificial/ intrauterine insemination
Women 40-42 offered 1 cycle of IVF if:
1. subfertile for 2y +/- after 12 cycles of AI
2. never had IVF
3. No evidence of low ovarian reserve
4. Informed about additional implications of IVF at this age
What are 3 indications for intracytoplasmic sperm injection?
Oligospermia
Poor fertilisation (DM, erectile dysfunction)
How is ICSI carried out?
Sperm directly injected into egg
What are 4 indications for donor egg with IVF treatment?
POI
BL oophrectomy
Gonadal dysgenesis
High-risk genetic disorder
What is intrauterine insemination?
Sperm injected through catheter into uterus
What should be looked for on examination in a male with sub-fertility?
BMI, secondary sexual characteristics/ gynaecomastia (hypogonadism)
Penis: position of urethral meatus (structural abnormality)
Scrotal exam: lumps (Ca, varicocele, hernia), small + soft (hypogonadism), undescended
