Subfertility Flashcards
Define infertility.
Failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sex.
What is the difference between primary and secondary infertility?
Primary - being unable to conceive at all
Secondary - losing the ability to conceive (i.e. already having a successful pregnancy)
What % of cases of infertility are unexplained?
25%
Describe the different ovulatory causes of infertility.
Type 1: hypopituitary failure (commonly caused by anorexia nervosa)
Type 2: hypopituitary dysfunction (e.g. PCOS, hyperprolactinaemia)
Type 3: ovulatory failure (menopause, premature if <40 y/o)
What is PCOS?
PolyCystic Ovarian Syndrome - means having 10+ follicles per ovary on US scan
What symptoms/signs according to the Rotterdam criteria must be met in order to have a diagnosis of PCOS?
2 out of 3 of:
- clinical hyperandrogenaemia
- oligomenorrhea (<6-9 periods/yr)
- polycystic ovaries in US
What physical symptoms can PCOS cause?
Menstrual disturbance Infertility Hirsutism Acne Male-pattern hair loss Central obesity Acanthosis nigricans
What clinical conditions must be excluded before making a diagnosis of PCOS?
Thyroid dysfunction
Congenital adrenal hyperplasia
Hyperprolactinaemia
Androgen-secreting tumour
Describe the different tubal and uterine causes of infertility.
- PID (can cause tubal scarring)
- Previous tubal surgery (inc. for ectopic pregnancy) = tubal scarring
- Endometriosis (tubal and uterine effects)
- Fibroids
- Cervical mucus defect (mucus can be ‘hostile’ to sperm)
What % of women develop tubal infertility after:
A. 1 episode of PID
B. 3 episodes of PID
a. 10%
b. 50%
What are some of the symptoms of acute PID?
Plevic pain Deep dyspareunia Malaise Fever Purulent vaginal discharge
What investigations are carried out to diagnose PID? What are the treatment options?
Investigations:
Endocervical swab (ECS) - microscopy, culture and sensitivity
STI test (especially for chlamydia)
FBC
Treatment:
Antibiotics
Rest
Abstinence
What is endometriosis?
Presence of tissue histologically similar to endometrium outside the uterine cavity and myometrium
How many women are affected by endometriosis? What are the risk factors?
1 in 5 affected
Risk factors: increased risk with age , FH, frequent cycles
What treatment options are there for endometriosis?
Combined oral contraceptive pill (COCP) Pregnany protect NSAIDs for pain Norethisterone Danazol GnRH agonist Surgery
What is another name for fibroids? What are they?
Uterine leiomyoma
Benign tumours of the SMOOTH MUSCLE of the myometrium
What are the different types of fibroids?
Named by location:
- subserosal
- pedunculated
- intramural
- submucosal
What treatment options are there for fibroids?
Tranexamic acid, COCP/LARCs, surgery
Describe the different male causes of infertility.
Testicular (infection, cancer, surgical, congenital, undescended + trauma)
Azoospermia with or without sperm antibodies
Reversal of vasectomy
Ejaculatory problems (retrograde and premature)
Hypogonadism
(diabetes and depression can causes erectile dysfunction)
What drugs have been linked to female/male/both causes of infertility?
Women: Long-term NSAIDs use, chemotherapy, neuroleptics, spironolactone, depo-provera
Men: Sulfasalazine, anabolic steroids, chemotherapy, chinese herbs
Both: marijuana, cocaine + other ilicit drugs
How long must a couple be trying to conceive for before getting a referral? In what cases are earlier referrals made?
2 years (as 90% of couples conceive within 2 years)
Earlier referrals if:
- woman >/= 36 years
- known cause of infertility.hisotry of predisposing factors of infertility
What investigations are carried out by a GP before referral to a fertility clinic is made?
Full sexual/contraceptive/fertility history
FBCs (fibroids or iron deficiency anaemia)
PCOS screen (Day 21 progesterone, LH, FSH, serum testosterone, glucose)
TFTs/TSH
Vitamin D
HbA1c
Viral screen (rubella, HIV, hepatitis screen)
STI screen and smear check
Maybe semen analysis
What are the normal values for sperm count in terms of volume, progressive motility, morphology?
volume: 1.5 mL
progressive motility: 32%
morphology: 4%
What kind of tests are carried out in secondary care to investigate ovulatory function, tubal function and uterine function?
ovulatory function = bloods, ovarian reserve testing (how would they respond to Gn stimulation)
tubal function = hystersalpinogram
uterine function = laparoscopy
What advice/treatment would be given to a female with hypopituitary failure?
increase weight, reduced excessive exercise
pulsatile GnrH or Gn with LH activity to induce ovulation
What advice/treatment would be given to a female with PCOS?
Make sure BMI is =30
Clomiphene (non-steroidal SERM) for 6 months MAX
Metformin
Combined clomiphene + metformin
laparoscopic ovarian drilling and Gn therapy
What advice/treatment would be given to a female with hyperprolactinaemia?
Bromocriptine (not safe in pregnancy)
What advice/treatment would be given to a female with ovarian failure?
Donor eggs/alternative parenting strategies
What advice/treatment would be given to a female with tubal/uterine infertility?
laparoscopic tubal surgery
surgery prior to IVF attempt for fibroids/endometriosis
adhesiolysis
What advice/treatment would be given for male infertility causes?
NOT MANY TREATMENTS :((
treat infections, surgery for testicular causes
gonadotrophins for hypogonadism
diabetes and depression support
What does ICSI stand for?
Intracytoplasmic sperm injection
What is the success rate for intrauterine insemination/IVF for women:
a. <35
b. >44
intrauterine insemination:
a. 15.8%
b. 0%
IVF:
a. 32.2%
b. 1.9%
