Subfertility Flashcards
Detection of Ovulation
Only real proof is conception
Elevated serum progesterone in mid-luteal phase –> ovulation
Measure 7 days before menstruation
Luteal phase is always 14 days regardless of cycle length, therefor in 35 day cycle measure on day 28
Urine LH kit detecting LH surge
Serial USS showing fall in size of corpus luteum - not practical and rarely done
Polycystic Ovary Syndrome
Clinical features Obese Acne Hirsutism Oligomenorrhoea/amenorrhoea Changes in weight affect severity of syndrome Miscarriage
Ix
Bloods: FSH normal in PCOS, decreased in hypothalamic disease, increased in primary ovarian failure
Prolactin to exclude prolactinoma
TSH to exclude hypothyroidism
Serum testosterone: could also be raised in congenital adrenal hyperlasia or androgen secreting tumour
LH
TVUS
Other
DM screening, lipids,
Complications: 50% T2DM, 30% GDM, endometrial carcinoma
Diagnostic criteria: 2 of 3 Visible polycystic ovaries on USS Irregular periods (cycles >35 days in length) Clinical or biochemical signs of hirsutism: acne, excess body hair, raised serum testosterone
USS criteria for Polycstic Ovary
TVUS appearance of 12 or more small 2-8mm follicles in an enlarged >10ml ovary
Tx Diet and exercise Normalisation of weight COCP Clomifene Cyproterone acetate = anti-androgen Spironolactone = anti-androgen Metformin Eflornithine = topical anti-androgen for facial hirsutism
Hypothalamic causes of Anovulation
Hypothalamic hypogonadism
Decrease GnRH –> Decrease FH/LSH –> No ovulation
Kallmann’s syndrome
GnRH secreting neurones fall to develop
GnRH pump induces ovulation
Pituitary causes of Anovulation
Hyperprolactinaemia
Excess prolactin –> Decreased GnRH
Tumours or pituitary hyperplasia
Symptoms Oligomenorrhoea Amenorrhoea Galactorrhoea Headaches Bitemporal hemianopia
Tx: Bromocriptine
Pituitary damage from Sheehan’s syndrome
Ovarian causes of Anovulation
Premature ovarian failure
Gonadal dysgenesis
Luteinised unruptured follicle syndrome –> egg is never released
Clomifene
First-line Tx in PCOS for induction
6 months use –> 70% ovulation, 40% live birth rates
Anti-oestrogen: blocks oestrogen receptor on hypothalamus –> Increase FSH and LH
Given 2-6 days –> initiates follicular maturation
Assess via TVUS
Increase stepwise 50mg–>100mg–>150mg
2< follicles, cancel cycle to avoid multiple preg
Causes endometrium thinning
Side effects of Ovulation Induction
Multiple Pregnancy
Ovarian hyperstimulation syndrome
Gonadotrophin stimulation –> large painful follicles
More common during IVF than standard induction
Risk factors Gn stimulation Age <25 Previous OHSS Polcystic ovaries
Should cancel IVF cycle if excessive follicle growth (witholding hCG)
Severe OHSS Hypovolaemia Electrolyte disturbances Ascites Thromboemolism Pulmonary oedema Death
Management of PCOS (Conceiving vs Not Conceiving)
Co-cyprindrol: is licensed for treating hirsutism and acne, although not specifically in PCOS. It is also used to induce regular endometrial bleeds and thereby reduce the risk of endometrial carcinoma.
COCP: is also used to control menstrual irregularity. If risk factors deem women ineligible, progestogens may be used to induce bleeds to protect the endometrium (eg, medroxyprogesterone 10 mg daily for 7-10 days every three months). Alternatively the IUS may be used as endometrial protection.
Metformin: has been increasingly used off-licence for PCOS; however, a Cochrane review showed it to be less effective than the COCP for menstrual irregularity, hirsutism and acne, and the National Institute for Health and Care Excellence (NICE) Evidence Summary suggests its side-effects and cost outweigh its benefits and any, as yet unproven, long-term health benefits.[11, 12] Metformin should not be initiated in primary care other than for diabetes; women considering metformin should be referred to secondary care.[1]
Eflornithine: may be used for hirsutism, as can cosmetic treatments (electrolysis, laser, waxing, bleaching). There is some limited evidence that eflornithine improves the appearance of facial hair in the short term; however, prescribing may depend on local policy.[13]
Orlistat: can help with weight loss in obese women with PCOS and may improve insulin sensitivity.
Oligomenorrhoea or amenorrhoea are known to predispose to endometrial hyperplasia and endometrial cancer in untreated cases. It is good practice to recommend treatment with progestogens to induce a withdrawal bleed at least every 3-4 months
FERTILITY
Clomifene: induces ovulation and has been proven to improve pregnancy rates. It should not be used for more than six months and, as it is associated with an 11% risk of multiple pregnancy, women should have ultrasound monitoring during treatment
Metformin: may be used instead of or together with clomifene to improve pregnancy rates, according to 2013 NICE guidelines. Women should be warned of the side-effects.
Laparoscopic diathermy
Laparoscopic ovarian drilling or gonadotrophins: are second-line treatments for those who are resistant to clomifene.
Male Subfertility
Idiopathic
Drug Exposure
Alcohol
Smoking
Drugs: Anabolic steroids , sulfasalazine
Varicocoele: varicosities of pampiniform venous plexus
Anti-sperm antibodies: common after vasectomy reversal
Other Epididmymitis Mumps Klinefelt's XXY Congenital absence of vas Cystic fibrosis Kallman's syndrome Retrograde ejaculation Prolactinoma
Causes of Tubal Damage
Tubes must be mobile to so fimbraial end collects oocyte from ovary
PID
12% infertile after one episode of PID
Infection at time of IUD insertion or ruptured appendix can be a cause
Increased rates of ectopic
Endometriosis
Previous surgery
(Any pelvic surgery)
Causes of Subfertility
Tubal Problems
PID
Endometriosis
Surgery
Cervical problems
Antibody production –> agglutinate sperm
Infection, cone biopsy
Sexual problems
Assessing Female Infertility
Dye test and laparoscopy
Methylene blue injected through cervix
Hysterosalpingogram
Radioopaque contrast injected through cervix
X-ray
Indications for Assisted Conception
Any/all methods have failed
Unexplained subfertility
Male factor subfertility (ICSI)
Tubal blockage
Endometriosis
Genetic disorders
Types of Assisted Pregnancy
Intrauterine insemination
IVF
ICSI
Oocyte donation
OGD
Surrogacy
