Subfertility Flashcards
When should investigations be offered for subfertility?
after 1 year of unsuccessful trying
What are the causes of sub fertility?
♣ Anovulation - 21% ♣ Male factor - 25% ♣ Tubal factor - 15-20% ♣ Unexplained - 28% ♣ Endometriosis - 6-8%
What are causes of anovulation?
→ Premature ovarian failure → Turner’s syndrome → Surgery → Chemotherapy → PCOS (accounts for 80% of anovulation) → XS weight loss or exercise → Hypopituitarism → Kallman’s syndrome
What should be taken from the Hx?
• Age and duration of subfertility
• Previous children?
• Menstrual Hx, regularity, pelvic pain, hx of STIs, previous surgery
• Smoking and alcohol reduces fertility
Male - undescended testes, mumps as an adult
What should be taken into account with the examination of subfertility?
- BMI - obesity has adverse effect on fertility
- Signs of endocrine disorder e.g. PCOS
- Pelvic pathology - endometriosis, fibroids
- Cervical smear, high vaginal and chlamydia swab
What investigations should be taken for sub fertility in primary care?
- Clap screening
- Baseline hormones - day 2-5 FSH and LH
- TSH, prolactin, testosterone and rubella status
- Mid-luteal progesterone level to confirm ovulation e.g. day 21 of cycle, >30nmol/L = ovulation
- Semen analysis - repeat in 3 m if abnormal after making lifestyle changes and starting multivits
What secondary care ix are given for subfertility?
- TVS - rule out adnexal masses, submucosal fibroids or endometrial polyps or PCOS
- HSG (Hysterosalpingogram)
− Using XR and contrast into the cervix to look at anatomy and tubal patency
− This ix can cause period like cramps and tubal spasm, giving false +ve
− Perform once clap swabs -ve and give azithromycin stat
Hysterosalpingo-contrast sonograph - Laparoscopy and dye test: gold standard for assessing tubal patency
What is involved in laparoscopy and dye test?
− Methylene blue dye injected through the cervix and tubes visualised w laparoscope
− Pelvic pathology can be treated at the same time
What is lifestyle management of subfertility?
→ Direct at the cause → Lose weight → Stop smoking → smoking → Exercise → Folic acid in the woman → Regular intercourse every 2-3 days
What are the different treatments involving ovulation induction?
Clomifene Laparoscopic ovarian drilling gonadotrophns Metformin Surgical techniques - Catheterisation or hysteroscopic cannulation Gonadatrophins Metform
When are gonadatrophins indicated?
Clomifene resistant PCOS or low oestrogen w normal FSH
What are the options in surgery for subfertility and what are they indicated for?
Catheterisation/cannulation to proximally blocked tubes Treating endometriosis (ablation, excision, coagulative techniques) Hysteroscopic adhesiolysis for intrauterine adhesions
When is IVF indicated?
- Tubal disease
- Male infertility
- Endometriosis
- Anovulation not responding to clomifene
- Subfertility due to age
- Unexplained infertility >2yrs
In who does IVF have a poorer response?
∞ Age ∞ duration of infertility ∞ Prev. Unsuccessful IVF ∞ Smoking ∞ High BMI ∞ Low anti-Mullerian hormone
What should be done to a couple before IVF?
screen them for HIV, hep B and C
Explain the process of IVF
- Stimulate ovaries
- Collect ova by TV aspiration under TVS guidance
- Fertilise ova
- 3-5 days later, return 1-2 embryos under US guidance to uterus
- Give luteal support in the form of progestagens
- Pregnancy test 2 weeks later
Where does spermatogenesis occur?
seminiferous tubules
What roles do FSH and LH and testosterone play in spermatogenesis?
FSH and LH important for starting it at puberty
LH stimulates Leydig cells to produce testosterone
FSH and testosterone stimulate Sertoli cells to produce essential substances for metabolic support of germ cells and spermatogenesis
How much of the volume of ejaculate does seminal fluid make up?
90%
Why is seminal fluid alkaline?
to buffer vaginal acidity
What is the % of normal form in sperm?
> 4
What is the normal total motility percentage in sperm
40
What is the normal progressive motility in sperm
> 40%
What is the normal conc of sperm
> 1.5x106ml
What is the normal volume of sperm
1.5ml
What % of causes of subfertility are male factors?
25
What are the different types of causes of male sub fertility?
semen abnormality (85%)
azoospermia
immunological
coital dysfunction
What are the different types of semen abnormality ?
idiopathic oligoasthenoteratozoospermia
testicular cancer
drugs - alcohol, nicotine
varicocele
What are the different causes of azoospermia?
pretesticular - anabolic steroid use, hypogonadotrophic hypogonadism, Kallman’s syndrome
non-obstructive - cryptorchidism, orchitis, Klinefelters, chemp
obstructive - congenital bilateral absence of the vas deferent, vasectomy, chlamydia, gonorrhoea
What are the immunological causes of male factor infertility?
anti-sperm abs
idiopathic
infective
What are the types of coital dysfunction contributing to male factor subfertility?
erectile dysfunction
hypospadias
retrograde ejaclation
failure in ejaculation - MS, spinal cord injury
What should be looked for upon examination in male factor sub fertility?
Body form and secondary sexual characteristics
Any gynaecomastia?
PR may reveal prostatitis
What are the ix in male factor sub fertility?
- Plasma FSH in testicular failure
- Testosterone and LH levels indicated in suspected androgen deficiency
- Karyotyping to exclude Klinefelters
- CF screen (associated w CBAVD)
What is the Rx involved in male factor sub fertility?
address alcohol and smoking
optimise underlying med conditions
multivits containing zinc, selenium and vit C
repeat semen analysis 3 m after changes made
intracytoplasmic sperm injection
What is the intracytoplasmic sperm injection?
- main tool for most male subfertility
Source of sperm is the epididymis or testis in men w obstructive azoospermia even if the problem is non-obstructive
