Subfertility Flashcards
What are important features to identify on history for women/couple presenting with subfertility?
Women
- Age, previous pregnancies, miscarriages etc
- Gyaencological and surgical hx, pap smear, STI hx, past contraceptive use
- Menstrual hx - irregular vs. regular, IMB, PCB
- Other signs of ovulation - midcycle pain, aware of changes in mucus
- Associated symptoms of PCOS, endometriosis, symptoms of early/premature menopause, hyperprolactinaemia
- Medical hx (blood clots, bleeding disorders, autoimmune conditions - thyroid, diabetes, SLE), medications, allergies
- FHx - infertility, miscarriages, clotting problems, premature/early menopause
- Lifestyle - smoking, alcohol, drugs
Man
- Age, children from previous partner
- Childhood hx mumps, testicular cancer, undescended testes, testicular trauma or surgeries
- Sexual dysfunction issues
- General medical
- Lifestyle - smoking, alcohol, drugs
Couple
- How long they have been trying
- How often they are having sex - time of month related to cycle, number of times and pattern when ovulating
- Used any ovulating aids
- Any relationship or mood issues
What are features to look for on examination for male and female with subfertility?
Female
- BMI - high or low
- Signs of PCOS - acanthosis nicgrans (insulin resistance), acne, hirutism
- VE - bulky, tender uterus, painful uterus on movement, cervical motion tenderness, discharge, adnexal mass/tenderness
Male
- BMI - high
- Testicular size, presence of both testicles, palpate for masses
- Secondary sexual characteristics - hair, gynaecomastia
What are first line investigations to perform for a couple presenting with sub-fertility?
Women - Mid-luteal phase progesterone to confirm ovulation (7 days pre-menstrual, day 21 if 28 day cycle)
Man - semen analysis (count, motility, morphology, antibodies)
What further investigations can be considered for women with subfertility?
Pelvic ultrasound - uterine size/shape/abnormalities (fibroids, polyps), evidence of endometriosis and endometriomas, PCO, saline sonohysterography (tubal patency)
FSH/LH - ovarian reserve, hypogonadal axis, premature menopause
Ix for PCOS - testosterone, FAI, SHBG
Laparoscopy + hysteroscopy - dye studies for tubal patency, endometriosis, adhesions, other structural abnormalities
Anti-mullerian hormone - more specialist test, assess ovarian reserve, may be helpful in older women or women with Rx affecting fertility
Coeliac Abs if indicated
STI screen
TFTs
Prolactin level
What conservative/lifestyle management for subfertility?
Dietary - general healthy diet, avoiding excess caffeine and alcohol
Exercise - general healthy exercise
Smoking cessation
Weight loss
Education on intercourse pattern and ovulation
- Ovulate midway through cycle (Day 14 if 28 day cycle but adjust accordingly), cervical mucus changes (thin and stringy)
- Have sex every second day just before and after menopause
- Explain most couples fall pregnant within 6 months and 90% by 1 year
- can do further Ix if taking longer than this
What are female DDx for women with subfertility?
- Affecting ovulation and eggs - PCOS, Coeliac disease, Primary amenorrhoea, Turners syndrome, High or low BMI, thyroid, hyperprolactinaemia
- Structural/Anatomical issues - Endometriosis, Structural uterine issues i.e. large fibroids, scarring, abnormal shape, PID/hx PID, Obstructed tubes (PID, endo)
- Egg factors - Age related decline in egg reserves/quality, premature/early menopause, iatrogenic induced menopause
- Other - Smoking, Excess caffeine, Systemic conditions i.e. anti-phospholipid syndrome, SLE
What are male and couple DDx for subfertility?
Azoospermia or oligospermia Abnormal motility or morphology of sperm Mumps Smoking Kleinfelters or other genetic syndromes
Behavioural - sexual patterns not appropriate (inadequate frequency and timing), sexual dysfunction
If women has irregular periods and/or anovulatory how would you further assess and what DDx do you consider?
FSH and LH levels
- High FSH = ovarian failure
-Age/physiological, early/premature menopause
-Genetic - Turners, Fragile X, FHx
-Iatrogenic - chemo/radiation/surgery
-Autoimmune - SLE, RA
-idiopathic
Consider donor ooycte and IVF - Low FSH = depression of hypogondal- pituitary axis (hypothalamic or pituitary issues)
-Stress/severe illness
-Low BMI
-Excess exercise
-Hyperprolactinemia - prolactinoma, medications
-Hypothyroidism
-Coeliac disease
Lifestyle modifications, ovulation induction therapies - Normal FSH = obesity, PCOS, hyperandrogenism
Weight loss and ovulation induction therapies (metformin, clomiphene)
What is the most common cause of anovulation subfertility?
PCOS
What is the most common cause of tubal related subfertility?
PID - scarring and tubal occulusion
What are the assisted reproductive options?
- Insemination - collection of sperm, placed into the uterus, low chance of pregnancy (~5%) can increase to ~10% if combine with ovulation stimulating therapies but increased risk of multiple pregnancy
- IVF +/- ICIS
- Stimulate multiple ovulation, harvest eggs
- Add sperm to eggs to allow fertilisastion - if poor sperm motility/quality can directly inject it into the ovum (ICIS)
- Transfer embryo to uterus (max 2 transfers)
- Transferred on Day 3 or 5 - Day 5 is highest success
- Can be a fresh or thawed cycle - thawed better/more successful but consider that will reduce total number of embryos as some may not survive freezing process - Donor eggs, donor sperm and/or surrogate
- Induction of ovulation in anovulatory women (i.e. PCOS) - clomiphene
What general information would you give on counselling about IVF?
- General success rate ~30%
- Poor sperm quality and egg quality most important factors - sperm more easy to overcome with ICIS
- Each cycle results in ~10 eggs, the number of embryos will be ~7-8 and if freezing several will not survive this process so may only be left with ~4 embryos with a good cycle
- Can do pre-implantation genetic screening on frozen embryos - increases success of pregnancy as transferring embryo with no aneuploidy
What is the serious complication that can occur with ovarian stimulation?
Ovarian hyperstimulation syndrome
Leads to haemorrphage, ascites and clots - increased vasculature
Signs to look out for = nausea + bloating
