subfertility Flashcards
Causes of subfertility
Ovulation disorders tubal problems uterine abnormalities endometrial pathology endometriosis general medical problems (DM, hypothyroidism)
What are some causes of ovulatory disorders
PCOS is biggest
Hyopthalamic hypogonadism
Hyperprolactinaemia
Last two are rarer causes of anovulation
What are some tubal problems?
PID (especially w/ chlamydia)
Endometriosis
previous pelvic/abdo surgery
What are some uterine problems
Fibroids
Endometrial polyps
Scarring (Asherman’s syndrome - can also result in lighter periods)
How can fibroids affect fertility
Submucosal - impact implantation
Intramural - impact implantation if large
Subserosal - have little effect
Male causes of subfertility
Age Damage to spertamogonial cells by INF Pelvic radiotherapy Ejaculatory problems Sex chromosome aneuploidy
Female Ix for subfertility
Early follicular phase (day 2/3) hormones (oestradiol, LH, FSH)
Mid luteal progesterone to confirm ovulation
If irregular menstrual cycle - prolactin, TFT, testosterone
Ovarian reserve - anti-mullerian hormone
STI screen
TVUSS to look at antral follicle - assessment of ovarian reserve
Tubal assessment by shysterosalpingography
If assisted conception is being trialled what should you check for?
HIV, Hep B+C
Assess ovarian reserve
TVUSS for antral follicle (<4 is bad, >16 is good). You can use this to predict response to assisted reproductive technology.
Also use AMH (produced by granulosa cells - not affected by gonadotrophin)
Male fertility analysis
Semen fluid analysis (vol, no., motility, pH, morphology)
Look at hormones if low sperm count or azoospermia
Medical management of subfertility
Ovulation induction (clomiphene or FSH) -for anovulation (PCOS or idiopathic) Intrauterine insemination (w/ w/ FSH stimulation) -unexplained subfertility, unresponsive anovulation, mild male problem donor insemination -azoospermia -single woman -same sex couple In vitro fertilisation -tubal pathology In vitro fertilisation w/ donor egg -poor egg quality
Indications for ovulation induction
Anovulation - PCOS, idiopathic
Can use clomiphene and FSH
How does clomiphene work
Binds to oestrogen receptors in hypothalamus
Blocks negative feedback and so leads to a surge in gonadotrophins
This encourages follicle maturation
What are some options for clomiphene resistant people
Augmentation w/ metformin
Aromatase inhibitor
Injectable gonadotrophin
If unresponsive to clomiphene you can do Laparoscopic ovarian drilling
Ovarian hyperstimulation syndrome
ascites, multifollicular ovaries, pulmonary oedema and coagulopathy
