Subfertility Flashcards
Requirements for contraception
Motile and normal sperm
- Able to reach and fertilise oocyte
Release of competent oocyte on time
Free passage for sperm to oocyte
Free passage for embryo to uterus
Mature endometrium for implantation.
Infertility
Inability to conceive after repeated unprotected intercourse
- 2 years
Can be investigated after 1 year
Top 5 common causes of infertility
Unexplained
Ovulatory
Male factor
Tubal
Endometriosis
Infertility statss
1 in 6 have problem with conceiving
Combined male and female factors accounts for 39% of the cause
Early investigation indications
- Female
> 35
Amenorrhoea/ Oligomenorrhoea
Previous abdo/ pelvic surgery
Previous STD/ PID
Abnormal pelvic examination
Early investigation indications
- Male
Previous genital pathology
- Testicular maldescent
- Surgery
- Infection
- Trauma
Previous STD
Systemic illness
Abnormal genital examination
Normal sperm count
> 15 million per ml
Normal sperm motility
> 40%
Normal sperm morphology
> 4%
Normal volume of semen
1.5-6 ml
Causes of azoospermia/ oligospermia
Primary testicular failure
- Most common
FSH/ LH/ Testo levels low
Y chromosome microdeletion
Cystic fibrosis
Female age and fertility
Fertility declines with age due to reduction in total oocytes
Also an increased rate of chromosomal abnormalities in oocytes
- Increased aneuploidy
- Increased miscarriage
Anti-mullerian hormone
Produced by Granulosa cells
- Pre-antral and small antral follicles
Good indicator of ovarian reserve
- Declines with age
Ovulation assessments
Ovulation detection kit [LH, urinary]
Cervical mucous
Basal body temperature
Follicular tracking- ultrasound scan
- Costly
Mid-luteal phase p4 (7 days before menstruation0
Mid luteal P4
Measurement of progesterone 7 days before menstruation
- >30 nmol/L = ovulation
Investigations for oligo/amenorrhoea
FSH/LH levels
- Normal in PCOS
- High in Premature ovarian failure
- Low in hypogonadotrophic hypogonadism
Oestrogen levels
- Normal in PCOS
- Low in POF
- Low in Hypogonado Hypogonad
Prolactin
Thyroid function
Androgens
SHBG
Most common cause of tubal damage
Pelvic inflammatory disease secondary to a chlamydia infection.
Proximal and distal tubal disease
Proximal less common (25%)
- Closer to the uterus
Distal (75%)
Factors that increase risk of tubal damage
Pelvic inflammation
- 54% risk after 3 episodes (12% then 23%)
Septic abortion
Ruptured appendix
Pelvic surgery
Ectopic pregnancy
Hysterosalpingogram (HSG)
- Description
- Infection
Fluoroscopy of uterus and tubes
- 2-5 days before menstruation
Antibiotics given to avoid infection flare-up
- 1% infection risk
HSG advantages and disadvantages
Advantages
- Relatively safe
- Easy
- Precisely highlights the uterine cavity and tubes.
Disadvantage
- Cannot assess the peritoneum
Hysterosalpingo-contrast- ultrasonography (HyCoSy)
Ultrasound that uses contrast medium
Advantages
- No radiation
- Can assess ovaries and uterus
Disadvantage
- Time consuming
- Requires training
Laparoscopy and dye [hysteroscopy]
Invasive
- Can diagnose and treat endometrisosis + adhesions
- More sensitive
- More specific
Risk of visceral injury
Imaging techniques best for detecting uterine abnormalities
Hysteroscopy- best
HSG
Transvaginal ultrasound
Clomifene citrate
Drug used to induce ovulation
- PCOS
Mechanism
- Inhibits oestrogen receptors in the hypothalamus–> Prevents inhibition of GnRH release
Multiple pregnancy risk
FSH injections
Used to stimulate ovulation
- Resistant PCOS
- Hypogonado hypogonad
Intrauterine insemination
- When it should not be offered
- Advantages
- Success rate
Unexplained infertility
Mild endometriosis
Low sperm count
Advantages
- Less stress
- Less invasive
- Less tech
- Cheap
Success rate
- 10% per cycle
NICE guideline for IUI
Not offered for unexplained infertility
- IVF instead
Offered for
- Single women
- Same sex couple
- Heterosexual w/ intercourse problem
IVF indications
Tubal damage
Low sperm quality
Unexplained infertility
Low ovarian reserve
IVF process
- Controlled ovarian hyperstimulation
- Egg collected
- Egg fertility in virto
- Intra-cytoplasmic sperm injection - Embryo left to develop
- Embryo transferred into uterus for implantation.
IVF success rate <35 years old
30-35%
