Subfertility 2 Flashcards
How does semen analysis take place?
sample collection
collect after 3 days abstinence
examine within 2 hours of collection
What is the normal volume of semen collected?
2-5ml
What does it mean if the volume is outside the normal range?
low may be androgen deficiency
high may be abnormal accessory gland
What is the normal sperm count?
> 20x10^6/ml
What does it mean if the sperm count is outside this range?
absence of all sperm (azoospermia) = sterility
fluctuates from day to day
abnormality high may be associated with subfertility
How is sperm motility graded?
grade 1 - rapid, linear progressive motility
grade 2 - slow/sluggish linear or non-linear
grade 3 - non-progressive
grade 4 - immotile
Forward progression is V IMP
What else is analysed in the semen?
morphology - >30% is normal (very variable, less predictive)
liquefication time within 30 mins
WBC in sample - ?infection, if pus cells then culture semen
How is the DNA of the sperm analysed?
integrity of sperm DNA is essential
perform the sperm chromatin structure assay (SCSA) to look at the stability of chromatin and then look at DNA fragmentation index (DFI)
How would testicular damage present an endocrine assessment?
high FSH and low AMH
How would obstructive disease present an endocrine assessment?
normal levels
How would hypopituitarism present an endocrine assessment?
low or undetectable FSH and LH
How would spermatogenic failure present an endocrine assessment?
high FSH
low AMH
azopermia
perform a testicular biopsy
What other tests can be carried out to assess the sperm?
cytogenetics - may see XXY or XYY karyotype, can screen for CF
Testicular biopsy - may demonstrate spermatogenesis
Reterograde ejaculation - rare
Immunological tests - can get autoimmunity to sperm antigens
What is the most successful way to treat male infertility?
ICSI - intracytopalsmic sperm injection
direct injection of single immobilised sperm into oocyte
similar pregnancy rates to IVF
slightly high incidence of genetic tract abnormality in children
How can ovarian hyperstimulation be prevented?
use lowest possible effective dose
US monitoring of follicular growth
withdrawing gonadotrophins for a few days
What is hysteroscopy used to investigate?
visualise uterine cavity
correct uterine septum, scar tissue, uterine polyps, endometriosis or uterine fibroids
What is laparoscopy used to investigate?
view and assess pelvic organs
correct endometriosis, tubal damage, hydrosalpinx (fluid-filled fallopian tubes), scar
tissue, uterine fibroids, ovarian cysts + tumours
What is laparotomy used to investigate?
treat uterine fibroids, large ovarian cysts, or ruptured ectopic pregnancy with
uncontrolled haemorrhage
How is PCOS treated?
advice regarding diet and exercise
normalisation of weight
treat with COCP
What causes hypothalamic hypogonadism?
reduction in hypothalamic GnRH release
usual with anorexia, women on diets, athletes and those under stress
How can hypothalamic hypogonadism be managed?
restore body weight if appropriate
exogenous gonadotrophins or GnRH pump will induce ovulation
Bone protection with contraceptive pill or HRT required
What causes hyperprolactinaemia?
prolactin reduces GnRH release
due to benign adenomas or hyperplasia of pituitary cells, also associated with PCOS, hypothyroidism and sue of psychotrophic drugs
How is hyperprolactinaemia managed?
dopamine agonist - dopamine inhibits prolactin
surgery if medical treatment fails or neuro symptoms
What are the other methods of managing male subfertility?
lifestyle changes
drug exposures addressed
wear loose fitting clothing and testicular cooling advice
FSH + LH +/- hCG to treat hypogonadotrophic hypogonadism
What are the causes of coital dysfunction?
Alcohol Hypotensives SSRIs Beta blockers Finasteride The pill Phenothiazides (loss of libido) Diabetes (erectile dysfunction) Cord pathology
What are the advantages of surgical division or removal of adhesions?
Pain relief from adhesions
Improved fertility
What are the disadvantages of surgical division or removal of adhesions?
Risk of creating further adhesions
Risk of bleeding and infection
Risk of injury to bowels and/or incontinence
What are the advantages of surgical management of endometriosis?
improves conception rates
symptomatic improvement in 70% patients
What are the disadvantages of surgical management of endometriosis?
difficult due to severe adhesions and anatomic distortion
risks of damaging bowel, bladder, blood vessels and ureters
