Subfertility Flashcards
Which cells secrete AMH?
Granulosa cells
What proportion of anovulatory infertility is caused by PCOS?
> 80-90%
What is the main mechanism by which hyperprolactinaemia causes 2dry amenorrhoea?
Inhibition of LH pulsatility
What is the test for biochemical detection of hyperandrogenism?
Free Androgen Index
What proportion of women with PCOS are overweight/obese?
40-50%
What is the estimated prevalence of endometriosis in infertile women?
50%
What is the prevalence of endometriosis in women of reproductive age?
2-10%
What endometrial thickness should be achieved prior to frozen embryo transfer?
5mm
Which contraception is most associated with delay in return of fertility?
Depoprovera
Up to 1 year
What percentage of >35yo will take longer than a year to conceive?
30%
Normal semen volume?
1.5 ml
Normal sperm concentration?
15 million/ml
Normal total number of sperm in ejaculate?
39 million per ejaculate
Normal total motility?
40%
Normal sperm forms?
4%
What outcomes favour letrozole over clomiphene?
Higher live birth rate
Lower multiple pregnancy rate
Lower incidence of OHSS
How does letrozole work as ovulation inductor?
Competitively and reversibly binds to haem component of CYP450 unit to reduce oestrogen production (selective E-receptor modulator)
Does not inhibit production of mineralocorticoids/corticosteroids
What is the NICE guidance for treatment of Group 2 anovulatory infertility?
Clomiphene for 6/12
Lap ovarian drilling or clomiphene + metformin or gonadotropins
What is the treatment for Group 1 anovulatory subfertility?
Optimise BMI (>19) Pulsatile GnRH or gonadotrophins with LH activity
What is the chance that laparoscopy confirms findings of tubal occlusion at HSG?
35%
What is the treatment for male infertility secondary to Kallman’s?
Gonadotrophins or pulsatile GnRH pump
What percentage of male infertility is due to post-testicular causes?
40%
What is the average pregnancy rate with ICSI?
33%
What percentage of women with recurrent miscarriage have antiphospholipid antibodies?
What is the background population risk?
15%
<2%
What is the live birth rate in women with recurrent miscarriage associated with antiphospholipid antibodies with no intervention?
10%
What are the main causes of infertility in the UK (and percentages)?
Unexplained - 25% Ovulatory - 25% Tubal - 20% Male - 30% Uterine or peritoneal - 10% 40% - disorders in both female and male
What are the Rotterdam criteria?
- Polycystic ovaries (>=12 peripheral follicles or volume >10cm3)
- Oligo- or anovulation
- Clinical and or biochemical evidence of hyperandrogenism
What are the recommended screening tests for PCOS?
TSH
PRL
Free Androgen Index (testosterone and SHBG)
If testosterone >5 - 17hydroxyprogesterone
What measures predict high response to gonadotrophins in IVF?
Total antral follicle count >16
AMH >25
FSH <4
What measures predict low response to gonadotrophins in IVF?
Total antral follicle count <4
AMH 5.4
FSH >8.9
What percentage of tubal factor infertility is due to proximal disease?
What is the most common cause?
15%
Salpingitis isthmica nodosa
What are the criteria for negligible transmission rates of HIV (ie when can normal sexual intercourse take place in men with HIV) where male is HIV positive
Man compliant with HAART
Viral load <50 for more than 6/12
No other infections
Unprotected intercourse is limited to time of ovulation
If met sperm washing doesn’t reduce chance of transmission
What percentage of male factor infertility is secondary to hypogonadotrophic hypogonadism?
<1%
Which circulating androgens can activate receptors?
DHT
Testosterone
NOT DHEAS
How is testosterone metabolised and excreted?
In the liver into androsterone and etiocholanolone, conjugated, and excreted as 17-ketosteroids in the urine
What metabolic problems are there in CAH?
Deficiency of synthesis of cortisol
Most common - deficiency of 21 hydroxylase activity (90-95%)
What is the incidence of raised prolactin in infertile but ovulatory women?
3.8-11.5%
What are the surgical indications for prolactinomas?
How are prolactinomas treated in pregnancy?
- Failure of medical therapy
- Expanding lesion with neurological or ophthalmological deficits not responding to med therapy
- Pituitary apoplexy (potentially life threatening haemorrhage/infarction)
8.5% of macroprolactinomas may need surgery in pregnancy - continue medical treatment (usually stops in early pregnancy in microprolactinomas
What are the applications of AMH in fertility practice?
- Predicting over-response and OHSS and altering stimulation protocols accordingly
- Predicting poor response to stimulation and altering protocols accordingly to optimise oocyte yield
- Diagnositc marker in PCOS (high levels associated with high androgens and insulin insensitivity)
- Counselling re: poor response to avoid disappointment
Male factor alone contributes what percentage of infertile couples?
30%
What percentage of infertile couples have both male and female factor infertility?
40%
What proportion of men with low sperm quality have no cause found?
50%
What is the role of FSH in sperm production and which cells respond to it?
Increases spermatogonial number and matures to spermatocytes
Binds to Sertoli cells
What is the role of LH in sperm production and which cells respond to it?
Necessary for testosterone production by Leydig cells
Essential role in spermatid maturation
How long is spermatogenesis?
3 months
What type of male infertility is characterised by decreased FSH, LH and testosteone?
Pretesticular - hypogonadotrophic hypogonadism
What type of male infertility is characterised by elevated FSH and LH, low testosterone, with non-obstructive azoospermia?
Testicular failure - hypergonadotrophic hypogonadism
Can have isolated FSH rise with normal LH and testosterone - isolated spermatogenic failure without Leydig cell damage
What is the prevalence of varicocele in men with normal and abnormal semen?
11.7% and 25.4%
What type of male infertility is characterised by normal FSH and LH with evidence of complete spermatogenesis at biopsy?
Post-testicular
What number of men with varicocele have a concurrent renal abnormality?
30%
What are the indications for IUI?
- Mild male factor infertility
- Immunologic infertility
- Mechanical problems of sperm delivery
(Up to 6 cycles recommended by NICE)
What are the indications for ICSI?
- Uncorrectable severe male factor infertility
2. Fertilisation failure in previous IVF cycle
What are pregnancy rates per embryo transfer following ICSI?
33%
How much less is the chance of pregnancy with a man >40yo vs >35yo?
50%
What is the rate of twin pregnancy following single and double embryo transfer?
Single - 2%
Double - 25-30%
What is the lifetime incidence of infertility?
17% (1 in 6 couples)
At what stage of the menstrual cycle should HSG be performed?
Day 7 - 12
Sens: 53%
Spec: 87%
1-3% risk pelvic infection
What is HyCoSy?
Hysterosalpingo contrast sonography
water soluble contrast TVUS
Avoids radiation exposure
What is the risk of perforation and ectopic pregnancy with tubal catheterisation?
Perf - 2%
Ectopic - 3%
What is transvaginal hydrolaparoscopy (THL)?
0.4-0.6L fluid into posterior fornix
Small diameter endoscope
Can visualise POD, adnexa, tubes and perform small procedures e.g. ovarian drilling under LA as OP
Risk of bowel perf 0.61%
What is the difference between salpingoscopy and falloposcopy?
Salpingoscopy is the endoscopic visualisation of the
endosalpinx of the tubal infundibulum and ampulla at
laparoscopy and/or THL, whereas falloposcopy is the
endoscopic visualisation of the whole endosalpinx at
hysteroscopy
What is fertiloscopy?
Fertiloscopy is an outpatient technique that combines
hysteroscopy, THL and salpingoscopy
what is the best assay for measuring chlamydia trachomatis antibodies?
Micro-immune fluorescence (MIF)
How many cases of tubal infertility are due to proximal disease?
15%
What is salpingitis isthmica nodosa (SIN)?
- Most common cause proximal tubal infertility
- Inflammatory aetiology associated with infective PID stigmata
- Endosalpingeal diverticula encased in myosalpingeal hypertrophy and fibrosis resulting in a firm proximal tubular nodule which can be seen on laparoscopic examination
- Can be mimicked by endo
By how much do ongoing pregnany rates increase following salpingectomy for hydrosalpinx?
x2
What are good prognostic factors for successful reversal of sterilisation?
Age <35
Residual length >4cm
What % of women presenting with subfertility are hyperthyroid?
- 3%
1. 5% general population
