Subfertility Flashcards
Infertility
Disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse
Primary infertility
Woman unable to ever bear a child, either due to inability to become pregnant or inability to carry a pregnancy to a live birth
–> miscarriages, ectopics, abortions and stillborns
Secondary infertility
Woman unable to bear a child, either due to inability to become pregnant or inability to carry a pregnancy to live birth following either a previous pregnancy or a previous ability to carry a pregnancy to a live birth
Subfertility Causes
Ovulatory Disorders (25%) Tubal Damage (20%) Uterine/peritoneal disorders (10%) Male factors (30%) Unexplained (25%)
Ovulatory causes
Type 1- Hypopituitary failure (anorexia)
Type 2- Hypopituitary Dysfunction e.g. PCOS, hyperprolactinaemia
Type 3- Ovarian Failure
PCOS
2 out of3 of:
Clinical hyperandrogenaemia
Oligomenorrhea (less than 6-9 periods/year)
Polycystic ovaries on ultrasound
PCOS signs
Menstrual disturbance (oligomenorrhea, amenorrhea, DUB) Infertility hirsutism Acne Male pattern hair loss Central obesity Acanthosis nigricans
PCOS medical signs
Raised LH with normal FSH
Raised testosterone
PCOS exclusions
Thyroid dysfunction
Congenital adrenal hyperplasia
Hyperprolactinaemia
Androgen-secreting tumours
PCOS associated metabolic abnormalities
Abnormal serum lipid concentrations
Insulin resistance
Tubal + Uterine causes of Infertility
Pelvic inflammatory disease Previous tubal surgery Endometriosis (uterine + tubal) Fibroids (uterine) Cervical mucus defect
Pelvic Inflammatory disease- Acute
May be asymptomatic Pelvic pain Deep dyspareunia Malaise Fever Purulent vaginal discharge
PID Examination
Cervical excitation
Adnexal tenderness
Discharge
pyrexia
PID Investigation
ECS- MC+S plus chlamydia, FBC, raised ESR
PID Management
Antibiotics
Rest
Abstinence
Chronic PID
From inadequately treated acute PID
Endometriosis
Presence of tissue histologically similar to endometrium outside uterine cavity + myometrium
Most commonly found in pelvis
Endometriosis RFs
Age
FH
Frequent cycles
Endometriosis symptoms
Pain
Dysmenorrhoea
Menorrhagia
Dyspareunia
Endometriosis exam
Pelvic tenderness or mass
Fixed uterus
Endometriosis management
NSAIDs Norethisterone Danazol GnRH agonists Surgery
Fibroids
Uterine leiomyoma
Benign tumours of smooth muscle of myometrium
Fibroids types
Subserosal
Intramural
Pedunculated
Submucosal
Fibroids symptoms
Heavy, regular periods
Fibroids management
Tran acid
COCP/LARCs
Surgical
Male causes infertility
Testicular- infection, cancer, surgical, congenital, undescended testes, trauma Azoospermia Reversal vasectomy Ejaculatory problems Hypogonadism
Drugs linked to infertility- WOMEN
Long term NSAID use Chemotherapy Neuroleptics Spironolactone Depo-provera
Drugs linked to infertility- MEN
Sulfasalazine
Anabolic steroids
Chemotherapy
Chinese herbs for improving sperm count + motility
Drugs linked to infertility- BOTH
Marijuana
Coke
Other illicit drugs
Investigations by GP prior to infertility referral
Full sexual/contraception/fertility history PCOS screen- day 21 progesterone, LH, FSH, serum testosterone, glucose FBC TSH Vit D HbA1c HIV Hep Rubella STI screen
Sperm count ranges
Volume (ml) LRL 1.5ml
Progressive motility (%) LRL 32%
Morphology (%) LRL 4% normal
Assessing tubal function
HSG
HyCoSy
Assess uterine function
Laparoscopy
Ovulatory disorder- Type 1 hypopituitary failure Management
Increase weight
Decreases exercise
Pulsatile GnRH
Ovulatory disorder- Type 2 PCOS Management
Wight loss to BMI 30 or below
Clomiphene or Metformin
Laparoscopic ovarian drilling
Gn therapy
Ovulatory disorder- Type 2 Hyperprolactinaemia Management
Bromocriptine
Ovulatory disorder- Type 3 Ovarian Failure management
Donor eggs
Tubal/uterine infertility Management
Laparoscopic tubal surgery
Surgery prior to IVF to attempt fibroid/endometriosis clearance
Adhesiolysis
Endo treatment
Male infertility treatment
Treat infections
Hypogonadism- consider gonadotrophins
Erectile dysfunction- DM control, depression support
Clomiphene
Medication used to treat infertility in women who do not ovulate
Includes those with PCOS
Intrauterine insemination (IUI)
Sperm is separated in lab Slower sperm removed
Partner inseminated
–> those who can’t have vaginal intercourse
15.8% success under 35
IVF
Fertilisation of egg outside body
32.2% live births under 35
IVF better if
Age Less cycles Previous pregnancies BMI 19-30 No smoking No caffeine
Ovarian hyperstimulation syndrome
Consequence of drugs used to stimulate ovarian function
Gonadotrophin or clomiphene
REFER
Intracytoplasmic Sperm Injection
Embryologist selects single sperm to be injected directly into egg
–> severe deficits in semen quality, obstructive + non-obstructive azoospermia
IVF risks
Small increased risk of borderline ovarian tumours
Cancer + preserving fertility
Cryopreservation before chemo
