Subfertility Flashcards
Physiology of the menstrual cycle, including ovulation
Demonstrate understanding of the hormonal changes in early pregancy
High levels of beta-hCG and relaxin
Both oestrogen and progesterone levels are low but gradually increase throughout pregnancy.
Understand in detail the principles underlying semen analysis
If results are abnormal then a repeat test should be offered in 3/12, to allow time for spermatogenesis to occur
Understand in detail the principles underlying endocrine evaluation
Male endocrine evaluation
- Testicular failure - elevated plasma FSH
- Failure of spermatogenesis in the semi-inferous tubules leads to loss of negative feedback to the pituitary gland by inhibin. Hence, FSH secretion continues.
- Androgen deficiency - elevated LH and reduced testosterone
- LH stimulates testosterone synthesis. If T synthesis is absent then there is loss of T mediated negative feedback on the pituitary gland, resulting in elevated LH levels.
- Low levels of FSH, LH and testosterone (hypogonadotrophic hypogonadism) is usually due to a pituitary tumour, most commonly a benign prolactinoma. Serum prolactin levels will be elevated.
Female endocrine evaluation
- Day 21/luteal phase progesterone: Serum is assessed 7 days after the assumed ovulation. > 9.5 nmol/L is indicative of ovulation. If the first value is indeterminate then sampling from days 21-28 may be used, with any ring across the luteal phase being suggestion of ovulation.
- Urinary LH
Demonstrate understanding of the diagnosis and management of common causes of subfertility
(including ovulatory dysfunction, male factor subfertility, tubal disease, endometriosis, coital dysfunction and unexplained infertility)
SEE TABLE ON NOTES
Demonstrate knowledge and some experiene of ultrasound screening of pelvic organs
- May be performed transvaginally or externally
- Allows for visualisation of abnormalities such as fibroids, uterine abnormalities, cysts and ovarian appearance/motility
Describe the complications of ovulation induction
Ovulation induction aims to induce the maturation of follicles, to increase ovulation.
- Weight loss/gain
- Laparoscopic ovarian drilling
Pharmacological methods:
- Oestrogen receptor antagonists: Act by reducing oestrogen mediated negative feedback on the HPG axis, allowing for increased release of FSH. FSH is then able to induce follicular maturation. Examples include clomiphene, tamoxifen or letrozole
- Gonadotrophins
- Insulin sensitisers: Metformin
- Aromatase inhibitors:
Ovarian hyperstimulation syndrome:
- Overstimulated ovarian follicles release VEGF, which increases vascular permeability.
- This allows for movement of intravascular fluid into the extravascular space, causing fluid to accumulate within the abdomen and pleural spaces.
- Intravascular fluid depletion leads to haemoconcentration and hypercoagulability (increasing risk of DVT and PE).
Multiple pregnancy
- The maturation of multipl follicles increases the likelihood of multiple pregnancy
Ectopic pregnancy
Miscarriage
Use of gonadotropins for ovulation induction is associated with more complications.
Be aware of the indications and complications of operative investigative procedures including diagnostic laparoscopy, hysteroscopy and tests of tubal patency.
Be aware of the issues relating to the diagnosis, investigation and management of tubal patency.
Tubal patency must be established prior to ovulation induction or intrauterine insemination.
Diagnosis:
Infertility and its associated investigations can cause a great deal of stress for couples
Investigations:
- Delays in imaging
- Sensitive topics such as sexual history, STIs etc. must be explored to assess risk of tubal adhesions/damage
Management:
There is increased risk of ectopic pregnancy after any form of tubal surgery.
Be aware of the advantages and disadvantages of surgical interventions for subfertility, including adhesiolysis, surgical management of endometriosis, myomectomy.
Be aware of the impact of the Human Fertilisation and Embryology Act on gamete donation and surrogacy.
- Bans sex selection of off-spring due to non-medical reasons
- Recognises same sex couples as legal parents of children conceived through the use of donated sperm, eggs or embryos
Outline the causes of subfertilty
