Subfertility Flashcards
When should investigation for sub fertility be offered?
After 1 year of trying
Earlier if female aged >35, amenorrhoea, oligomenorrhoea, PID, undescended testes or cancer treatments
What are causes of subferitlity?
Anovulation Mal factore Tubal factor Unexplained Endometriosis
What can cause an ovulation?
Premature ovarian failure Turner's syndrome Surgery chemotherapy PCOS Excessive weight loss or exercise Hypopituitarism Kallman's syndrome Hyperprolactinaemia
What history in subfertility?
Age
Duration of sub fertility
Any previous pregnancies
Does either partner have a child/children
Menstrual history, regularity, pelvic pain
History of STIs
Previous surgeries (tubal or for ectopic pregnancy)
Smoking
Drinking
Medical histoyr
Drugs
Frequency of sexual intercourse
Any problems during sex including erectile dysfunction
Male: History of undescended testes Mumps aas an adult PMHx DHx Smoking Drinking
What examination in subferitliy?
BMI - obesity has an adverse effect on fertility
Signs of endocrine disorders e.g. PCOS
Pelvic pathology e.g. endometriosis or fibroids
Take cervical smear if due
High vaginal and chlamydia swabs
What investigations in primary care in subferitlity?
Chlamydia screening
Baseline hormonal profile (FSH and LH)
TSH, prolactin, testosterone and rubella status
Mid-luteal progesterone to confirm ovulation (7 days before expected period e.g. day 21 if 28 day cycle, >30nmol/L is indicative of ovulation)
Semen analysis - repeat in 3 months if abnormal after making lifestyles changes
What investigation is used to confirm ovulation?
Mid-luteal progesterone level - 7 days before expected period
>30nmol/L indicates ovulation
What investigation in secondary care for subfertility?
Transvaginal scan to rule out adnexal masses, submucosal fibroids or endometrial polyps or help confirm PCOS
Hysterosalpingogram - x-ray and contrast injected through cannula in he cervix to demonstrate uterine anatomy and tubal patency
- May cause period-like cramps and tubal spasm, giving false positives
- Only perform once chlamydia swabs are negative and give azithromycin 1g stat
Hysterosapingo-contrast sonograph
- US contrast and TVS
Laparoscopy and dye test - day case procedure and gold standard for assessing tubal patency
Dye injected through the cervix whilst the tubes are visualised with a laparoscope
Used first line if strong clinical suspicion of tubal abnormality
What lifestyle modification can be made fo subfertility?
Lose weight
Eat healthy diet
Stop smoking
Reduce alcohol consumption less than recommended limits
Regular intercourse every 2-3 days - avoid timed intercourse
Avoid ovulation monitors - increase stress and no evidence of benefit
What are methods of ovulation induction?
Weight loss or gain Comifene citrate Laparoscopic ovarian drilling Gonadotrophin Metformin
What is clomifene citrate? Side effects/risk?
Anti-oestrogen which increases endogenous FSH via negative feedback to the pituitary
10% multiple pregnancy rate
Can create hot flushes, labile mood
Only use for 6-12 cycles (possible link with ovarian cancer)
Follicular monitoring by US
What are the criteria for clomifene citrate prescription?
Tubal patency confirmed
Semen count normal or near normal
BMI<30-35
When is laparoscopic ovarian dill used? How does this work?
Used in patients with PCOS
Small holes drilled into each ovary using diathermy to reduce LH and restore feedback mechanisms
Who is metformin used in?
Women with PCOS
Possible small increase in ovulation rates but it is not licensed and weight loss is more effective
What are surgical techniques for subfertility?
Tubal disease:
May respond to tubal catheterisation or hysterscopic cannulation
Endometriosis: Laparoscopy and ablation
Intrauterine adhesions: Hesteroscopic adhesiolysis
What are indications for in-vitro fertilisation?
Tubal disease Male factor sub fertility Endometriosis Anovulation not responding to clomifene Subfertility due to maternal age Unexplained subfertility > 2 years
What does success of IVF depend on?
Age duration of subfertility Previous pregnancy (higher success rate) Smoking High BMI (lower success rate) Low Anti-Mullerian Hormone predicts poorer response
Describe IVF
Ocariesa re stimulated
Ova collects by transvaginal aspiration
Fertilised
3-5 days later, 1-2 embryos returned under US guidance to the uterus as an outpatient procedure
Luteal support is given as progestogens
2 weeks later woman should do pregnancy test
What are criteria for NHS funded assisted conception?
Couples with no children
Non-smokers
BMI < 30Under 42 years of age
what are subferitliy options?
Donor insemination - when male partner has azoospermia (male semen has no sperm) or in high risk of transmitting genetic disorder or HIV or for women with no male partner
ICSI - Intracytoplasmic sperm injetion (directly into an egg) - sperm taken from ejaculate or surgically from the testis
Used when semen parameters are severely abnormal or failed fertilisation with IVF cycles or concerns about genetic mutation transmission
Intrauterine insemination
Useful in mild male macros sub fertility, coital difficulties and same sex couples
IVF
IVM - in vitro maturation
Immature eggs are collected from ovaries and matured in the lab before sperm injection - avoids expensive ovulation inducing drugs and risk of ovarian hyper stimulation
Where does spermatogenesis stake place? What hormones aid this?
Spermatogenesis takes place in seminiferous tubules
LH stimulates Leydig cells to produce testosterone
Testosterone and FSH stimulate Sertoli cells to produce the essential substances for metabolic support of germ cells and spermatogenesis
What is involved in semen analysis? Normal?
Volume > 1.5ml Concentration > 15x10^6/ml Progressive motility > 32% Total motility > 40% Normal forms > 4%
What are male factors that cause subferitlity?
Seme abrnormality
- idiopathic, testicular cancer, alcohol, nicotine, varicocele
Azoospermia
- pre-testicular (anabolic steroid use, hypogonadotrophic hypogonadism, Kallmann’s syndrome)
- Non-obstructive (crytorchidism, 47XXY Kinelfelter’s syndrome)
- Obstructive: vasectomy, chlamydia, gonorrhoea
Immunological:
Anti-sperm antibodies
Coital dysfunction
- erectile dysfunction
- hypospadias, phimosis, disability
- retrograde ejaculatin
What is normal testicalr volume?
15-25ml
What treatment in male factor subferitlity?
Lifestyle - smoking drinking
Optimise medical conditions
Multivitamin containing zinc, selenium and vitamin C
Repeat semen analysis in 3 months after making changes
ICSI - intracytoplasmic sperm injection
Sperm taken from ejaculate or surgically from the testis
Used when semen parameters are severely abnormal or failed fertilisation with IVF cycles or concerns about genetic mutation transmission
What hormone measured for ovulation test? When?
Progesterone 7 days before end of cycle
Following ovulations, FSH and LH cause dominant follicle to form corpus luteum
Corpus luteum produces surge of progesterone
How does low BMI affect fertility?
Hypogonadotrophic hypogonasism
Ant pit stops producing FSH and LH meaning follicles do not develop sufficiently
When should couples be referred to a specialist?
Regular intercourse (every 2-3 days) for 12 months For fertility testing
When should early referral for subfertility be considered?
Female: >35 Amenorrhoea Previous pelvic surgery Previous STI Abnormal genital examination
Male: Previous genital surgery Previous STI Varicocoele Significant systemic illness Abnormal genital examination
