Subfertility Flashcards
What are 4 key aspects of achieving fertilty?
- Ovum
- Sperm
- Fallopian tube
- uterus
What is subfertility?
- The failure to conceive after 1 year of unprotected intrcourse in the absence of known reproductibe abnormalities
- Affects 1 in 7 couples
Signs:
- woman > 35
- Infrequent/ no periods
- Pelvic infections
- Undescended testes
- Known reason (chemotehrapy/ radiotherapy)
How do you assess subfertility in females (History)?
- Ovulation : Menstrual regularity, ovulation awareness, PCOS, tyhroid or prolactinoma symptoms, weight changes, exercise
- Tubal disease : PID, pelvic surgery, ectopic pregnancy
- Endometriosis : Dysmenorrhoes, dyspareunia, dyschezia
- Previous contraception/ Obstertric history/ surgical/ medical illness/ Medicines/ cancer treatment
- Lifestyle: smoking, alcohol, recreational drugs, job
How do you assess male subfertility (History)?
- Sexual history: coital frequency, erectile or ejaculatory dysfunction
- Past medical illness (mumps), surgery (varicocele, hernia, hydrocele)
- Occupation, current medical illness (diabetes, hypertension), smoking, alcohol, recreational drugs)
How do you examine female subfertility?
-Smear/swabs :
- Speculum
- Vagina
- Cervix
- Bimanual:
- Uterus : position/mobility
- size/regularity
- Adnexal masses
- Tenderness
- TV scan generally done and superior
How is subfertily examined in males?
- Testis
- Epididymis
- Vas deferens may be absent - unable to carry the sperm
How do you investigate subfertility in females?
- Semen assay
- Ovulation
- Tubal patency
- Check for endometriosis
- Uterine patholofy
- Check rubella status/ chlamydia screening/ cervical smear
How do you evaluate/ investigate male partners (subfertility)?
- Check semen volume (ml)
- Sperm concentration (15 (12-16) = low)
- Progressive sperm motility
- Sperm morphology
- Repeat Sperm assay after 3 months of the first test is abnormal - sperm cycle ~ 3 months
- Repeat SA sooner if azoospermia or severe OA
- Screening for anti-sperm antibody not offered
What is azoospermia?
- when there are no sperm in the ejaculate
- Obstructive vs Non-obstructive
- FSH/LH
- Testosterone
- Prolactin
- Karyotype and Cystic Fibrosis
- Scrotal/trans-rectal scan
- Y micro-deletion
How do you investigate ovulation in subfertility?
TVS :
- Predictive = developing follicle. Will see a LH surge.
- Confirmatory = Collapsed follicle = progesterone tested on day 21
Tubal patency :
- Low risk:
- HysteroSalpingoGraphy
- OPD
- Cavity
- Level of block
CONS:
- Irrradiation
- Discomfort
- ## False positivesHysteroContrastSynography
Transvaginal USS
No irradiation
OPD
Alternative to HSG
Cavity less clear
What is high risk tubal patency?
- Laparascopy and Dye
- More information
- Adnexae
- Endometriosis
- Treatment
- Morbidity
- Discomfort
What is the initial advice given to couples?
- Age dependent
- Increase frequency of intercourse:
- 2-3 days per week
- 5 days before up to ovulation day
- LH kit/ BBT no use (stressful intervention)
- Healthy lifestyle :
- optimise weight/ healthy diet
- No smoking
- Limit alcohol intake
- Folic acid around conception time
- Continue up to 12 weeks
- 0.4 or 5 (for some) mg generally
MALE
- Measures to reduce scrotal temp :
- Loose fitting underwear
- Avoid hot baths
- Laptops
Zn/Se/Omega 3/ Vit E
What is the treatment pathway (Primary care phase)?
Treatment pathway (Primary care)
Primary Care Phase
Patients/CoupIe present With infertility problems
[1]
GP Assessment and Advice
GP to inform patient of access criteria for NHS funded assisted conception.
[2]
Investigations and tests completed as necessary.
(Refer to proforma on page 8 of this document).
[3]
Refer for advice
- Baseline FSH & LH/ Mid-luteal progesterone
- Prolactin/ TSH, free T4/ Testosterone, SHBG
- Chlamydia/ Rubella screen/ Cervical smear
- Advise on funding criteria
- Advise both couple should attend the clinic
What is the secondary care treatment pathway?
Treatment pathway (Secondary care)
Referral received — accepted/rejected
[41
First out-patient appointment— both partners should attend
Additional investigations!LaparoscopyfHSG/repeat sperm tests
Follow up appointment
Rejected —
back to GP
Endometriosis
Laparoscopy
Tubal
Tubal
Surgery
Male Factor
Ovulation
Unexplained
Clomifene or
Tamoxifen
*POF Primary Ovarian Failure
Further investigations
- HSG/TVS
- Laparoscopy (if indicated)
- Repeat SA/Endocrine/ Scan Scrotum/Karyotype (if indicated)
- Review in a few weeks to plan a definitive mgt
How is male subfertility managed?
Management of male subfertility
Idiopathic
Hypogonadotrophic hypogonadism
Lifestyle
Antioxidants: Vitamin E, Selenium,
Glutathione, Zinc (Wellman/menovit)
Male factor fertility problems
bstruceve
Surgery
I to
If no pregnancy with azoospermia, bilateral tubal occlusion or 2 years’ infertility and the woman is aged 23-
39 years offer I cycle
of IVF/ICSI
* availability/patient choice
(IUI not recommended
By NICE 2013)
How is azoospermia treated?
- Surgery- urologist
- Surgical sperm recovery (PESA/TESA/TESE) generally done at IVF unit- offer regardless of FSH levels
- Testis biopsy
How is anovulation managed?
Management of anovulation
Group 1 - 10%
Hypothalamic pituitary
failure
( Anorexia Nervosa)
Group Il - 85%
Hypothalamic pituitary
dysfunction (PCOS)
Group Ill — 5% - Ovarian Failure :
* Hyperprolactinaemia
* Low Gonadotrophins
* Low oestrogen
* Normal Prolactin
* Normal oestrogen
* Gonadotrophin
* disorder
* High Gonadotrophins
* Low oestrogens
* High prolactin
Restoration of body
weight
GnRH
FSH / LH
Clomiphene/Metform
Gonadotrophins
Ovarian drilling
Oocyte donation
Dopamine agonists
Gonadotropins
What is the approach to treat PCOS?
Anovulation: PCOS
Step-by-step approach…..
1st line non-pharmacological management tor infertility
1st line pharmacological managernent for infertility
Letrozole*
(consider Letrozole 1st line therapy)
Gonad0trophins
1
Cbmiphene
Citrde
Clomiptme
+ metformin
Lifestyle interventions
1
2nd line pharmacological/surgical management
Laparoscopic ovarian surgery
v/ 5-10% W body weight
spontaneous ovulation
- should precede ovulation
induction
3rd line nunagenmt could be other appropriate interventions including IVF
* Off label prescribing: Letrozole, COCPs. metformjn and other pharmacological are generally off liel in PCOS. as pharmaceutical
companies have not applied for approval in PCOS However. off label use is predominantly evidence-based and allowed in rnany countries.
Where it is allowed. health professionals should inform women and discuss the evidence, possible and side effects of tredment.
Costello et al 2019 HRO International consensus on PCOS
Anovulation
PCOS
body weight
Step-by -step approach
spontaneous ovulation
How is tubal disease/ endometriosis treated?
Tubal disease/ Endometriosis
Tubal
Endometriosis
Mild tubal disease:
Tubal surgery
Proximal tubal occlusion:
Tubal catheterisation or cannularion
Minmal\mild endometriosis:
Surgical ablation or resection
and at laparoscopy
If no pregnancy, offer:
Stimulated IUI up to 6 cycles
Moderate’severe endometriosis
Surgery
IN-VITRO FERTILIZATION
How is unexpexted subfertility treated?
Unexplained
Spontaneous cumulative pregnancy rates 33-60% at 3 years
* Low natural conception in women > 35 years age
Management :
Expectant
IUI
IVF
What is the criteria for NHS funding for IVF / ICSI
Criteria for NHS funding
Women’s Age - under 40 years = 1 cycle
Women’s age - 40-42 if they have nevrr had IVF and no evidence of ovarian reserve
BMI
Welfare of the child Family
Structure
Smoking - both parents must be non-smoking
How does IVF/ICSI treatment work?
1.) Stimulate follicle growth
2.) Aspiration of oocytes
3.Oocyte mixed with spern
4.) IVF
5.) Development of embryp
6.) Embryo transfer
What is embryo transfer?
Embryo transfer
Under 36, 1st cycle — recommend single blastocyst transfer — ongoing SET preg rate over 50%
Choice of embryo numbers (SET recommended) based on :
NHS Funded cycles
Female age
Previous histoty
EmblY0 numbers and quality
Blastocyst transfer
Under 36 1 95
ongoing SET preg rate over 50 %
Choice of embryo numbers ( SET recommended based on :
- NHS funded cycles
- Female age
- Previous history
- Embryo numbers and quality
- Blastocyst transfer
What is Luteal support?
Progesterone
Started two days after egg collection
Cyclogest pessaries 400mg BD (PV Of PR)
Gestone injection (1M)
Continued for 14-16 days until pregnancy test
Continued upto 10-12 weeks of pregnancy
Offered a review/ counselling if not pregnant
What is embryo freezing?
- Surplus embryos of good quality can be frozen for future use
- 90-95% of embryos survive the process
- FER can be carried out in a cycle supported by HRT or in a natural cycle
- Similar pregnancy rate (like that of fresh cycle)
What are the risks of IVF?
Risks of IVF
Complications/Side Effects
OHSS
Failed Fertilisation
Risk no sperm on day
Miscarriage
MAF
? fertility of children
Freezing: not all suitable
Not all survive
OHSS
Cancellations
Failed Cleavage
*Multiple Pregnancy
Ectopic Pregnancy
Success Rate/
Modifiers
Folic Acid
