Subfertility Flashcards
What is the definition to subfertility?
The abilty to conceive after 12 months of regular unportected sexual intercourse.
Regular intercourse is defined as 2-3 times per week. Maximum “efficiancy” is achieved if intercourse is had at least every other day
When taking a Hx, always ensure the couple is having proper vaginal sex (some people have no idea how it should work….)
What is the incidence of subfertility?
In the UK, around 1 in 7 couples are affected.
What are the likelyhoods of a healthy couple to conceive:
- Per cycle
- Within 6 months
- Within 12 months
- Within 24 months?
- Per cycle: 18-20%
- Within 6 months: 70%
- Within 12 months: 84%
- Within 24 months: 92%
Name some general and lifestyle factors that affect fertility.
- Age: Significant decline in women >35 (decline in oocyte quality and quantity)
- Smoking: reduces both female and male fertility
- Coital frequency: minimum 2-3 timesper week recommended.
- Stress: can impact the HPO axis, interfering with normal ovulation, and decreasing libido (i.e. frequency of intercourse)
- Alcohol: affects sperm quality, and is harmful to foetus. Moderate amounts are OK.
- Body weight: both low and high extremes associated with reduced chance of conception
- Drugs: NSAIDs inhibit ovulation (as prostaglandins are involved). Other durgs also implicated in infertility
- Occupational exposure: Chemicals and radiation adversly affect male and female fertility.
What are the categories of female causes of subfertility?
- Ovulatory disorders
- Group I: Hypothalamic-pituitary failure
- Group II: Hypothalamic-pituitary-ovarian dysfunction (PCOS)
- Group III: Ovarian failure
- Tubal problems
- Uterine problems
- Lifestyle/functional factors (cigarette smoking, high and low BMI, libido)
What are the commonest causes of female subfertility?
Common causes of subfertility include:
- Ovulatory disorders such as PCOS and natural decline in fertility with age
- Tubal damage secondary to infection (most common cause worldwide) or endometriosis
- Cigarette smoking
- High and Low BMIs.
What are male factors of subfertility?
Sperm:
- Compromised quantitiy or quality, due to:
- Post-orchitis/epididimytis (e.g. after Hx of Mumps)
- Iatrogenic: Pelvic radiotherapy, surgery for undescended testes
- Diabetes
- Heat
- Chemicals
- Erectile dysfunction/Ejacuatory dysorder
- Genetic factors (Klinefelter XXY and others)
What invetigations would you like to perform for a couple presenting with infertility?
Male investigations (1/3 of infertility is caused by penis-humans):
- Seminal fluid analyses (total volume, sperm concentration, morphology, motility)
- Repeat after 3 months if abnormal, as certain factors such as viral infections can lead to false negatives
- Consider karyotyping and screen for CF
Female:
- Day 2-4 FSH (the more FSH is required to stimulate follicles, the lower the ovarian reserve is)
- Day 8 LH (at day 8, LH should be inhibited by inhibin. If it is raised, this suggests PCOS)
- Oestradiol
- Mid-lueteal progesterone (should be raised if ovulating. i.e. day 21 in 28 day cycle)
- Endocrine check: TFT, prolactin, testosterone
- Test for STI: chlamydia. HIV (and Hep B/C)
- TVUSS: assess pelvic anatomy, looks for fibroids, antral follicle count
- Tubal potency assessment: Hyterosalpingogram or Hysterocontrast synography. In women with known co-morbidities (e.g. endometriosis) do laparoscopy and dye test.
(Anti-Mullerian Hormone can also be used to predict for ovarian reserve, but we were tuaght this is less commonly used)
Describe the management approach/available options for subfertility
Management should be individualised and involve optimisation of the patient’s current medical problems e.g. thyroid disease. The different approaches that can be taken include:
- Lifestyle changes
- Ovulation induction
- Surgery
- Intrauterine insemination
- In-vitro fertilisation
How successful is IVF?
In patients under 35, the success rates are 40-45% per cycle.
In women >40, the rates fall below 15%.
What is ovarian hyperstimulation syndrome?
OHSS is a condition that can arise as part of the hormonal treatment of IVF.
It is usually the hCG injection that leads to large release of several hormones, causing ascites, enlarged multifollicular ovaries, pulmonary oedema and coagulopathy.
It affects 1-3% of women undergoing IVF.
How can subfertility be categorised?
WHO categorises infertility into:
- Failure to conceive may be primary which means the woman has never before been able to bear a child.
- Or may be secondary meaning although the woman has previously had children, she is now unable to bear further children.
What percentage of subfertility is caused by male or female (or both) factors?
30% caused by male factors
30% caused by female factors
25% is unexplained
15% caused by both male and female factors
What are the common causes of female subfertility?
Common causes of subfertility include:
- Ovulatory disorders such as PCOS and natural decline in fertility with age
- Tubal damage secondary to infection (most common cause worldwide) or endometriosis
- Cigarette smoking
- High and Low BMIs.
What:
- Ovulatory disorders
- Tubal disorders
- Uterine problems
commonly cause infertility?
Ovulatory disorders
The commonest cause of problems with ovulation is PCOS, furthermore hormonal management of PCOS (COCP, progesterone) interfere with fertility. Hypothalamic disorders, pituitary disease and endocrine abnormalities are less common causes of anovulation.
Tubal problems
Tubal blockage is usually associated with inflammatory processes in the pelvis such as pelvic inflammatory disease or endometriosis. Chlamydia in particular can produce significant degrees of tubal damage.
Previous pelvic or abdominal surgery can also result in scar tissue or adhesions that can compromise tubal function.
Uterine problems
Uterine problems such as fibroids can interfere with pregnancy, depending on size and location. Asherman’s syndrome (Endometrial scarring) from surgery or infection can be associated with lighter periods and a significantly reduced change of conception.
