Subfertility and its Causes Flashcards
What is the definition of subfertility?
Failure to conceive after a year of regular unprotected intercourse
What is the pathology behind subfertility?
- Ovulatory problems
- Male sperm problems
- Tubal problems
- Cervical problems
- Sexual problems (psychological)
Describe the normal process of egg maturation?
- At the beginning of the cycle low oestrogen levels cause increased levels of GnRH and consequently FSH and LH
- These hormones stimulate the maturation of several ovarian follicles
- The oocyte follicles produce estradiol which has a neg feedback effect so that FSH and LH levels fall
- The effect of this is that only one dominant follicle will survive
- As this oocyte follicle matures, more and more estradiol is produced, exerting a positive feedback effect on FSH and LH (surge)
- The oocyte ruptures and the follicle becomes the corpus luteum
What factors can cause ovulatory problems?
- Group I: Hypothalamic hypogonadism/pituitary failure (anorexia, exercise, stress)
- Group 2: hypothalamic-pituitary-ovarian dysfunction (PCOS), hyperprolactinaemia (pituitary adenomas)
- Hyper/hypothyroidism
- Ovarian failure
What is the definition of PCOS?
USS appearance of multiple (>12) small follicles in an enlarged ovary
This is because, due to hyperandrogenism, all the eggs mature equally (but not enough), without one dominant follicle maturing. These accumulate on the edge, causing anovulation.
These woman display disordered LH production and peripheral insulin resistance (higher risk of GD)
How is PCOS diagnosed?
2/3 of:
- PCO on ultrasound
- Irregular periods (cycle >42 days)
- Raised testosterone (hirsutism, biochemical markers, acne)
What investigations should be done for a person with suspected PCOS?
Bloods: LH, FSH, TFTs, prolactin, testosterone, fasting lipids and glucose
Imaging: transvaginal USS
How should the menstrual irregularity of PCOS be managed?
Lifestyle modification, weight loss, combined oral pill, metformin
How should anovulatory sub fertility be managed conservatively?
Lifestyle changes and treatment of associated disease
How should sub fertility in association with PCOS be managed?
CLOMIFENE
- antioestrogen
- fools pituitary into believing there is no oestrogen, so it produces more FSH and LH
- monitor cycles by vaginal ultrasound for 6 months
METFORMIN
- also symptomatic treatment
LAPAROSCOPIC OVARIAN DIATHERMY/DRILLING
- punch through membranes so that the eggs can come out more easily
How should hypothalamic hypogonadism be treated?
- Daily SC injection of FSH and LH
2. GnRH pump
What factors can cause abnormal sperm release?
Drugs, genetic, varicocele, antiserum antibodies, infections
How is sub fertility investigated?
- Semen analysis
- Endocrine evaluation
- Tubal patency
- Pelvic USS screening
- Laparoscopy (and dye test)
- Hysteroscopy
What are the common causes of tubal problems?
- Infection (PID)
- Endometriosis
- Previous surgery/sterilisation
How does intrauterine insemination work?
Inject washed sperm directly into the cavity of the uterus
INDICATIONS: unable to have sex (physical, psychological), same sex couples
How does IVF work?
Embryos fertilised outside the uterus and transferred back (requires normal ovarian reserve)
Often the follicles are given GnRH analogue to help maturation
What are the risks associated with IVF?
- Miscarriage/ectopic
- Preterm delivery
- Multiple pregnancy
What is intracytoplasmic sperm injection?
Injection of one sperm right into the oocyte cytoplasm. This is usually used for male factor infertility
What is the normal semen count?
> 15 million/mL
What is the normal progressive motility of sperm?
> 32%
What is asthenospermia?
Absent or low motility of sperm
What is ovarian hyperstimulation syndrome?
OHSS has been characterized by the presence of multiple luteinized cysts within the ovaries leading to ovarian enlargement and secondary complications. It is categorised into mild, moderate and severe
What are the symptoms of OHS?
Mild/moderate - Abdo swelling (fluid build up), nausea, vomiting
More severe -severe dehydration, oliguria, VTE
What is chronic pelvic inflammatory disease?
Adhesion formation and hydrosalpinx within and around the fallopian tubes due to repeated acute PID
What are the symptoms of PID?
Chronic pelvic pain, dysmenorrhoea, heavy/irregular menstruation, chronic vaginal discharge, adnexal tenderness
What causes PID?
The main cause is sexual (chlamydia)
How should PID be investigated?
Bedside: Vaginal swabs
Bloods: FBC, CRP, blood cultures
Imaging: Pelvic USS, laparoscopy (gold standard)
How should acute PID be treated?
Antibiotics (doxycycline and metronidazole) and analgesia
What are the complications of acute PID?
- Pelvic abscess
- Chronic PID
- Chronic pelvic pain
- Subfertility
- Ectopic pregnancy
What is endometriosis?
The presence and growth of tissue similar to endometrium outside the uterus
What are the symptoms of endometriosis?
Deep dyspareunia, pelvic pain, dysmenorrhoea, dyschezia, dysuria, subfertility, bleeding (due to ruptured chocolate cyst)
These symptoms are due to the endometriosis being abnormally affected by the hormones that affect the normal endometrium
What causes endometriosis?
Retrograde menstruation
What does endometriosis look like on laparoscopy?
White scars/brown spots - less active
Red vesicles/punctuate marks - active
Mild - red dots
Moderate - large raised red/black vesicles
Severe - multiple adhesions/cysts and white areas of scarring with surrounding abnormal blood vessels
How is endometriosis managed medically?
Mimic pregnancy/menopause (combined oral contraceptive, GnRH analogues)
NB - these do not improve conception as they are contraceptives
How is endometriosis managed surgically?
Laparoscopic diathermy/ablation to destroy endometriotic lesions (HELICA)
Drainage and stripping of ovarian endometrioma cysts
Hysterectomy and bilateral salpingo-oophorectomy
NB - these provide symptomatic relief but the risk of recurrence is high
What is done at a fertility pre assessment clinic?
General tests and lifestyle modification
Tests of ovulation: mid luteal serum progesterone (day 21 - indirect test of egg production)
Semen analysis
Tubal assessment
Pelvic scan: PCO, assess fibroids, ovulation
What is mild male factor subfertility?
Two or more semen analysis having one or more variables below the 5th centile
What are the normal values for semen analysis?
Volume 1.5 ml Count 15 million/ml, 39 million/ejaculate Motility 40% Progressive motility 32% Normal morphology 4%
What are the effects of obesity on fertility and pregnancy?
Effects on ovulation, follicular growth, implantation and embryo development
Increased risks of miscarriage, pregnancy complications and labour problems
How does endometriosis cause infertility?
Distortion of pelvic anatomy and inflammatory effects
What can cause tubal sub fertility?
- Hydrosalpinx (surgery, infection) - fluid in this cyst is embroytoxic
- Chlamydia
How can tubal subfertility be investigated?
Hysterosalpingogram - use dye to investigate tubal patency and identify location of obstruction
Laparoscopy (if HSG is abnormal) - look for cysts and adhesions
What are adhesions?
Fibrous bands that form between tissues and organs, often as a result of surgery or any inflammation. They can be thought of as internal scar tissue that connects tissues that are not normally connected
What uterine factors can cause subfertility?
- Uterine septum (do hysteroscopic resection)
- Fibroid uterus that distorts the cavity (do myomectomy, UAE)
- Endometrial polyps
- Intra-uterine adhesions (do adhesiolysis)
- Uterine abnormalies (bicaronuate, unicornuate)
Why do people with CF sometimes suffer from infertility?
Congenital bilateral absence of the vas deferens
