Subfertility Flashcards
Definition of subfertility
The Failure to conceive after 1 year of regular unprotected intercourse
Incidence of subfertility
1 in 6/7 couples
84% of couples will conceive within 1yr of regular sex and 94% within 2yrs.
Effects of personal factors on chance of conception
Prior pregnancy - 1.8x
<30yrs - 1.5x
Male or tubal defect - 0.5x
Endometriosis - 0.4x
Causes of Subfertility
Male factor
Anovulation
Tubal factors
Other hormonal factors
Causes of Anovulation
Hypothalamic or Pituitary dysfunction (high prolactin) Thyroid dysfunction (low T3) Ovarian Failure PCOS (high LH and testosterone)
PCOS
A tonic elevation of LH and mildy high testosterone
treat with clomiphene, nuserelin+hMG, ovarian diathermy or drilling
Ovarian Failure
hyper- or hypo- gonadotrophic hypogonadism - depending on if there is high or low FSH/LH
if necessary treat with ovum donation
Tubal Factors
Can be due to Infection (PID or STI), surgery, ectopics or endometriosis
Inspect with a hysterosalpingogram
Investigating the Male Factor
Measure sperm count - if normal wait and investigate the women
If low measure FSH - if normal check for obstruction, if high indicates testicular failure
Causes of male subfertility (6)
Infections (mumps or STIs) Congenital problems
Trauma Varicocele
Radiotherapy Drugs
Semen analysis
2-5ml of semen which should have a sperm density of >15x10^6/ml
40% or more should be progressively motile, with 32% being rapidly progressive
At least 4% should be morphologically normal
Ratio of infertility categories
1/3 each male, female and combined
Male sterilisation
simple OP under LA/GA which works after a couple of hours, x2 semen analysis before UPSI (16 & 20wks). 5-30% will have complications (chronic testicular pain, bruising, sperm granuloma, infection, haematoma)
Failure rate is 1/2000 and reversal is 55% 10yrs.
Female Sterilisation
Day case Laparoscopy under GA, increased risk of ectopic if fails (1/200).
Rate of successful reversal is 50-60%
Ovarian hyperstimulation syndrome
a potentially fatal complication of 33% of IVF where >20 follicles grow leading to very high eostrogen.
Mild OHS
bloating, abdo pain and ovaries <8cm
Moderate OHS
Moderate abdo pain, N&V, USS ascities, ovaries 8-12cm
Severe OHS
clinical ascities, oligouria, ovaries >12cm, increased haematocrit and serum protein
Critical OHS
tense ascities or hydrothorax,
Haematocrit >55%, raised WCC, anuria, thromboembolisms and ARDS
Risk factors for OHS
Women with PCOS are at increased risk
Younger women and those with high eostrogens or more follicles. BhCG or GnRH supplementation
Basic investigations of infertility
Semen analysis (>15m/ml, >50% motile, >4% morphology normal, >1-6.5ml) Serum progesterone 7 days before period. (30 indicates ovulation)
Advice for couples trying to conceive
Folic acid
Aim for BMI 20-25
Advise for regular sexual intercourse every 2-3days
Smoking and drinking advice.
Forms of Male infertility
Few sperm (oligozoospermia) No sperm (azoospermia) No semen (Aspermia) Little semen (hypospermia) Low motility (Asthenozoospermia) Deformed sperm (Teratozoospermia) Leucospermia (WBCs in the semen, can indicate infection) Necrozoospermia (all sperm are dead)
Development of Sperm
Spermatagonia (46x1) replicate by mitosis and one daughter cell replicates chrs to become a primary spermatocyte (46x2) which then divides into 2nary spermatocytes (23x2) which divide into spermatids (23x1) which mature into spermatazoa
