Subfertility Flashcards
What is sub fertility?
Failure to concieve after 12 months of regular unprotected sex
How many people are affected by sub fertility?
1 in 7 couples
What is the chance of a healthy couple conceiving within a single menstrual cycle?
20%
What are important factors for fertility?
- main factor
- modifiable factors
Female age
Also: smoking, stress, BMI extremes
What age does fertility drop off sharply for women?
36
What age does fertility drop off sharply for men?
50
How long does sperm survive for in the reproductive tract?
Up to 72 hours
What medication must women commence immediately if they are planning on getting pregnant?
Folic acid
What are categories of problems that could cause subfertilitY?
Ovarian
Tubal
Uterine / endometrial
General medical conditions
What is the most common ovarian cause of sub fertility?
PCOS (due to oligomenorrhoea)
Hypothalamic hypogonadism
Pituitary disease
What are tubal problems that cause sub fertility?
BLOCKAGE of tubes
PID
Endometriosis
previous pelvic / abdominal surgery
What is the main uterine cause of subfertility? And other secondary causes
FIBROIDS
Polyps
Ashermann’s syndrome (endometrial scarring)
What are important investigations for sub fertility?
Blood hormone profile
- Early follicular phase FSH, LH, estradiol
- Mid luteal progesterone (confirms ovulation)
Screening:
- Chlamydia
- HIV, Hep B and C (if ART is being used)
- TVUSS
What are two key measurements of ovarian reserve?
AFC - antral follicle count (seen on TVUSS)
AMH
Why is AMH a measure of ovarian reserve?
Because it is produced by granulose cells in the antral follicles
So it is a biomarker of ovarian reserve
How do you assess tubules?
Using hysterosalpingography
What are medical treatments for subfertility?
Medical:
- ovulation induction (clomiphene/FSH)
- intrauterine insemination (with/without FSH stimulation)
- donor insemination
- IVF
- Donor egg with IVF
What are surgical options for subfertility?
Operative laparoscopy - treat disease, restore anatomy
Myomectomy
Tubal surgery
Laparoscopic ovarian drilling
How does clomiphene work?
It binds to oestrogen receptors in the hypothalamus / pituitary, blocking the negative feedback exerted by oestrogen
This leads to LH/FSH surge >stimulates ovary to recruit more follicles
What is a risk for women on clomiphene?
They risk multiple pregnancies
What surgical method is good for ovarian induced action in PCOS?
laparoscopic ovarian drilling
How is intrauterine insemination performed?
Introducing a small sample of prepared sperm into the uterine cavity with a fine uterine catheter
What kind of tracking is done to ensure there is no follicular overstimulation?
Follicular tracking with US
How does IVF work?
- Downregulate pituitary with GnRH agonist - this will prevent LH and FSH release > LH surge > ovulation
- Controlled ovarian stimulation with LH, FSH (daily doses)
3,. Inhibits premature ovulation with GnRH agonist still - hCG trigger (surrogate for LH surge) allows ovulation
- Egg collection (needle into ovaries, aspirate follicular fluid + oocyte)
- Fertilisation in Petri dish with 100k sperm
- Embryo culture
- Embryo transfer (transfer into uterus using soft plastic catheter)
What is the key risk with IVF?
Ovarian Hyperstimulation Syndrome
What are the four key presentations of Ovarian Hyperstimulation Syndrome
Monica And Octavia’s Childbirth
Multifollicular ovaries (enlarged)
Ascites
Oedema (pulmonary)
Coagulopathy
