SUBFERTILITY Flashcards by Merlin Hetherington

What percentage of couple trying to conceive will do so over the course of 1 year?

84%

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What percentage of couple trying to conceive will do so over the course of 2 years?

92%

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What is the definition of infertility?

Failure to conceive after regular unprotected sexual intercourse for 2 years

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What is the difference between primary and secondary subfertility?

Primary refers to couple who have never had a previous pregnancy, whereas secondary refers to those who have had a previous pregnancy.

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At what point do we investigate couples who are having trouble conceiving?

After 1 year of trying.

Investigation may be needed earlier if history reveals risk factors such as infection, menstrual irregularities or where female is over 35 years old

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In what percentage of couples struggling to conceive will the factor be only from the male?

22%

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In what percentage of couples struggling to conceive will the factor be only from the female?

57%

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In what percentage of couples struggling to conceive will the factor be only from both the male and the female?

21%

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What is considered frequent enough sexual intercourse in order to have a good chance of conceiving?

Every 2-3 days

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What key things should be asked about in a history from a women in a subfertile couple?

Duration of subfertility

Frequency of intercourse

Coital problems - female vaginismus, dyspareunia

Previous pregnancies, outcomes and modes of delivery, including ectopic.

Past gynae history - menorrhagia (fibroids), dysmenorrhoea (endometriosis), Asherman’s (adhesions), previous infections, oligo/ameno-rrhoea

Past medical history - chronic (renal/thyroid), eating disorders

Drug history - previous contraceptive use, regular use of NSAIDs, folic acid supplements

Social - smoking and alcohol, exercise and weight loss

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What are the female causes of infertility relating to ovulatory dysfunction?

Chronic systemic illness

Eating disorders

Obesity

PCOS

Hyperprolactinaemia

Hypo/hyperthyroidism

Cannabis use

NSAIDs

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What are the female causes of infertility relating to tubal anomalies?

Pelvic inflammatory disease

Previous surgery

Previous ectopic pregnancy

Endometriosis

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What are the female causes of infertility relating to problems with the uterus?

Fibroids

Uterine septae

Congenital anomaly

Asherman’s syndrome

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What are the female causes of infertility relating to coital dysfunction?

Vaginismus

Dyspareunia

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What key things should be asked in a history from a man in a subfertile couple?

Erectile/ejaculatory dysfunction

Past surgical history - inguinal hernia repair, undescended testes, testicular torsion, bladder neck surgery

Past medical history - cystic fibrosis (vas deferens obstruction), epididymo-orchitis (from STI), post-pubertal mumps (orchitis), chronic medical conditions (eg renal and diabetes)

Drug history

Social history - smoking, alcohol, occupational history (driving raises temp)

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What drugs can lead to male subfertility?

Anabolic steroids
Cannabis
Cocaine
Sulfasalazine (IBD)
Colchicine (gout)
Nitrofurantoin (Abx)
Tetracycline (Abx)
Alpha blockers - interere with ejaculation
Beta blockers

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What basic blood test is a first line investigation and should be done for a woman who presents as part of a subfertile couple?

Mid-luteal phase progesterone: performed a week before next period is due (normally day 21)

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What investigations should be done for a woman who presents as part of a subfertile couple?

MId-luteal phase progesterone

Pelvic ultrasound - structural abnormalities of uterus, ovarian cysts (PCOS), hydrosalpinx

Microbiology - screen for chlamydia

Hysterosalpingogram (HSG) or Hysterosalpingo contrast sonography (HyCoSy) - testing tubal patency

Dye guided laparoscopy can be used to find tubal occlusion (semen screen must have been done before this invasive procedure)

What investigations should be done for a man who presents as part of a subfertile couple?

Microbiology - screen for chlamydia

Semen analysis

What are the normal parameters in semen analysis?

Volume - 1.5-5 mls
Count - more than 20 million/ml
Progression - more than 50%
Normal forms - more than 30%

How should a man go about providing a semen sample for analysis?

3 days abstinence with at least a 72 hour history of good health

Sample should be examined within 1 hour of production.

Ideally two samples should be taken at least 12 hours apart

What about a semen analysis would suggest epididymo-orchitis?

Presence of more than 106 WBC

What do we define oligozoospermia as?

Less than 15 million/ml count

What do we define asthenozoospermia as?

Less than 32% motility

What do we define teratozoospermia as?

Less than 4%

What is the most common cause of male subfertility?

Oligo-terato-asthenospermia

How do you treat a woman who is subfertile due to anovulation?

Optimise general health - thyroid disease, diabetes Weight loss if high BMI Consider clomiphene (anti-oestrogen) to induce ovulation Consider adding metformin if overweight Consider ovarian drilling

What are the most important risks associated with clomiphene use?

Ovarian cancer Multiple prenancy

How do you treat a woman who is subfertile due to uterine, tubal or pelvic problems?

Often removed prior to IVF Hydrosalpinges are drained Endometriosis can be operated on Tubal blockage can be surgically removed

What is first line in the treatment of male factor infertility?

Intrauterine insemination (IUI)

How many cycles of intrauterine insemination should be tried before IVF?

Up to 6

What is in vitro fertilisation (IVF)?

Process of harvesting eggs and incubating them with sperm for 2-3 days. Subsequent fertilised embryo is transferred into the female.

What are the steps of IVF?

1. Down regulation of women's own hormones using GnRH agonists - leads to reduced oestrogen production. 2. Induction of multiple follicular development using gonadotrophins such as human menopausal gonadotrophin (hMG) which contains FSH and LH, and hCG (from urine of pregnant women) 3. Egg collection - transvaginal guided by US, under sedation 4. Sperm preparation 5. In vitro fertilisation for 2-3 days 6. Transfer of embryo

What is pre-implantation genetic diagnosis?

Technique whereby couples affected by hereditary disorder can screen embryos to see which may be affected.

What is intracytoplasmic sperm injection (ICSI)?

Advanced form of IVF where one sperm is directly injected into the egg. This has revolutionised treatment for those with very low sperm counts.

What are the risks of assisted reproductive techniques such as IVF and ICSI?

Multiple pregnancy Low birth weight ICSI shows higher risks of baby born with congenital malformations especially affecting urogenital system. Ovarian hyperstimulation syndrome

What is ovarian hyperstimulation syndrome?

Systemic disease caused by ovulation induction where levels of oestrogen are too high. As a result there is increased vascular permeability. Fluid therefore accumulates in the third space (abdomen, chest) and leads to intravascular depletion.

What are the clinical features of ovarian hyperstimulation syndrome?

If mild then just some abdominal discomfort If more severe, then nausea, vomiting, painful abdominal distension, ascites and pleural effusions.

What are the risks and complications of ovarian hyperstimulation syndrome?

Hepatorenal failure Adult respiratory distress syndrome (ARDS) VTE

How do we treat patients who suffer from an episode of ovarian hyperstimulation syndrome?

Admit Careful fluid balancing Thromboprophylaxis Therapeutic drainage of accumulated fluid

How can you reduce the likelihood of ovarian hyperstimulation syndrome during ovulation induction?

Ultrasound monitoring of patients undergoing procedure. May be necessary to abandon cycle if too many follicles have developed to prevent OHSS.

What is the most important prognostic factor in the success rate of IVF?

Maternal age

What are the chances of IVF being successful in a woman of between 23 and 35 years?

20%

What are the chances of IVF being successful in a woman of over 40 years old?