Subfertility Flashcards
When should investigations be offered for subfertility?
after 1 year of unsuccessful trying
What are the causes of sub fertility?
♣ Anovulation - 21% ♣ Male factor - 25% ♣ Tubal factor - 15-20% ♣ Unexplained - 28% ♣ Endometriosis - 6-8%
What are causes of anovulation?
→ Premature ovarian failure → Turner’s syndrome → Surgery → Chemotherapy → PCOS (accounts for 80% of anovulation) → XS weight loss or exercise → Hypopituitarism → Kallman’s syndrome
What should be taken from the Hx?
• Age and duration of subfertility
• Previous children?
• Menstrual Hx, regularity, pelvic pain, hx of STIs, previous surgery
• Smoking and alcohol reduces fertility
Male - undescended testes, mumps as an adult
What should be taken into account with the examination of subfertility?
- BMI - obesity has adverse effect on fertility
- Signs of endocrine disorder e.g. PCOS
- Pelvic pathology - endometriosis, fibroids
- Cervical smear, high vaginal and chlamydia swab
What investigations should be taken for sub fertility in primary care?
- Clap screening
- Baseline hormones - day 2-5 FSH and LH
- TSH, prolactin, testosterone and rubella status
- Mid-luteal progesterone level to confirm ovulation e.g. day 21 of cycle, >30nmol/L = ovulation
- Semen analysis - repeat in 3 m if abnormal after making lifestyle changes and starting multivits
What secondary care ix are given for subfertility?
- TVS - rule out adnexal masses, submucosal fibroids or endometrial polyps or PCOS
- HSG (Hysterosalpingogram)
− Using XR and contrast into the cervix to look at anatomy and tubal patency
− This ix can cause period like cramps and tubal spasm, giving false +ve
− Perform once clap swabs -ve and give azithromycin stat
Hysterosalpingo-contrast sonograph - Laparoscopy and dye test: gold standard for assessing tubal patency
What is involved in laparoscopy and dye test?
− Methylene blue dye injected through the cervix and tubes visualised w laparoscope
− Pelvic pathology can be treated at the same time
What is lifestyle management of subfertility?
→ Direct at the cause → Lose weight → Stop smoking → smoking → Exercise → Folic acid in the woman → Regular intercourse every 2-3 days
What are the different treatments involving ovulation induction?
Clomifene Laparoscopic ovarian drilling gonadotrophns Metformin Surgical techniques - Catheterisation or hysteroscopic cannulation Gonadatrophins Metform
When are gonadatrophins indicated?
Clomifene resistant PCOS or low oestrogen w normal FSH
What are the options in surgery for subfertility and what are they indicated for?
Catheterisation/cannulation to proximally blocked tubes Treating endometriosis (ablation, excision, coagulative techniques) Hysteroscopic adhesiolysis for intrauterine adhesions
When is IVF indicated?
- Tubal disease
- Male infertility
- Endometriosis
- Anovulation not responding to clomifene
- Subfertility due to age
- Unexplained infertility >2yrs
In who does IVF have a poorer response?
∞ Age ∞ duration of infertility ∞ Prev. Unsuccessful IVF ∞ Smoking ∞ High BMI ∞ Low anti-Mullerian hormone
What should be done to a couple before IVF?
screen them for HIV, hep B and C