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
