Subfertility Flashcards
Define subfertility
unwanted delay in conception after 1 year of regular (2-3x/week) unprotected intercourse
or failure to conceive after 6 cycles of intrauterine insemination
Risk factors for subfertility
increasing maternal age >40
BMI>30
smoking
OTC medications - NSAIDs can interfere with ovulation
recreational drugs (marijuana and cocaine interfere with ovulation and tubal function, cocaine and anabolic steroids affect sperm production)
General causes of subfertility
ovulation disorders eg. PCOS
tubal damage
male factor
unexplained
endometriosis
other eg. fibroids
What may prompt subfertility investigations to be started earlier than 1 year?
female factors:
- age >35
- previous ectopic pregnancy
- known tubal disease
- history of STD/PID
- tubal/pelvic surgery
- amenorrhoea/oligomenorrhoea
- psychosexual problems
male factors:
- testicular maldescent/orchidopexy
- chemotherapy/radiotherapy
- previous urogenital surgery
- history of STD
- psychosexual problems
Oligomenorrhoea defintion
cycle length 6 weeks - 6 months
Amenorrhoea definition
no natural period for 6 months or more
Amenorrhoea classifications
group 1 = hypothalamic-pituitary failure (GnRH)
group 2 = hypothalamic-pituitary-ovarian dysfunction (PCOS)
group 3 = ovarian failure (hypergonadotrophic hypogonadism, ovarian insufficiency)
Causes of amenorrhoea due to hypothalamic-pituitary failure
(reduced or absent GnRH or gonadotrophins)
hypothalamus:
- low body weight, stress, exercise
- craniopharyngioma, tumours
- Kallmann’s syndrome
- idiopathic
pituitary:
- Sheehan’s syndrome
- functioning pituitary tumours (prolactinomas)
- non-functioning pituitary tumours
- brain radiotherapy
- post-pituitary surgery
What is Sheehan’s syndrome?
infarction of pituitary after substantial hypovolaemia
PCOS symptoms
oligomenorrhoea
insulin resistance
weight gain/inability to lose weight
difficulty getting/staying pregnant
ovarian cysts
pelvic pain
anxiety/depression
acne
loss of hair on head (male pattern hair loss)
hirsutism
ROtterdam criteria for PCOS diagnosis
2/3 of:
- oligo-ovulation or anovulation
- clinical hyperandrogenism and/or biochemical hyperandrogenism
- unilateral or bilateral polycystic ovaries on pelvic USS (>12 antral follicles and/or ovarian volume >10cm3)
PCOS bloods
raised free testosterone
low sex hormone-binding globulin (SHBG)
low-normal FSH
normal-high LH
increased LH:FSH ratio
normal/borderline prolactin
Management of subfertility in PCOS
optimise health and weight
metformin
clomifene - risk of multiple pregnancy and ovarian hyperstimulation syndrome
ovarian drilling
gonadotrophin ovulation induction
IVF
Risks of clomifene
multiple pregnancy
ovarian hyperstimulation syndrome
Define oligospermia
reduction in concentration of sperm (<15 million/ml)
Define asthenospermia
reduction in motility of sperm
Define teratospermia
reduced specum percentge of normal shape (morphology)
Define azoospermia
no sperm in ejaculate
Define aspermia
no ejaculate
How can male factor infertility be sub-classified?
pre-testicular
testicular
post-testicular
Pre-testicular causes of male factor infertility
GnRH deficiency (Kallmann’s syndrome)
genetic disorders
haemochromatosis
pituitary/hypothalamus tumours
trauma (surgery/irradiation)
vascular
infiltrative (sarcoid, TB)
drugs
chronic illness, malnutrition
obesity
Testicular causes of male factor infertility
orchidectomy
testicular cancer
Klinefelter’s syndrome
Y chromosome deletions
5 alpha reductase deficiency
androgen insensitivity
varicocoele
infection
drugs/toxins/smoking
hyperthermia
anti-sperm antibodies
Post-testicular causes of male factor infertility
epididymis - obstruction, drugs, toxins
vas deferens - cystic fibrosis, obstruction, STIs
seminal vesicles and prostate
defective ejaculation - neurogenic, diabetes, ureterocele, urethral stricture, drugs, alcohol, endocrine, prostate surgery
Male factor infertility investigations
genital examination
semen analysis - 2-7 days after sexual abstinence - volume, sperm number, concentration, motility, progressive motility, vitality, morphology
endocrine tests:
- normal FSH + low testosterone = obstructive
- high FSH + low testosterone = primary hypogonadism (testicular)
- low FSH + low testosterone = secondary hypogonadism (pre-testicular)
- low FSH + high testosterone = anabolic steroid use
- prolactin
