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Subfertility/Infertility Flashcards

1
Q

What is infertility?

A

no chance of conception

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2
Q

What is subfertility?

A

Lower chance of conception

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3
Q

What is the definition of sub fertile?

A

A couple is sub fertile if conception has not occurred after 1 year of regular unprotected vaginal intercourse

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4
Q

What is regular intercourse?

A

Not less than 2 times a week

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5
Q

How common is subfertility?

A

15% of couples affected

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6
Q

What is primary subfertility?

A

Couple without a prior pregnancy

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7
Q

What is secondary subfertility?

A

Couple with a prior pregnancy (incl miscarriage, TOP)

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8
Q

What is the requirement of normal pregnancy?

A

Have to have egg, sperm, these need to meet and fertilise and then finally implant

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9
Q

What do the NICE guidelines suggest are the causes of subfertility?

A
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10
Q

What are the peak fertility years for females?

A
  • peak in late teens, early 20s
  • > 35 it becomes an issue
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11
Q

When is a male considered fertile?

A

Spermatogenesis at puberty and fertile >60

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12
Q

What are some general impacts on fertility?

A
  • BMI = anorexia (women <19) and obesity (>30)
  • C2H5 intake (women should have none while TTC and men should stay within recommended guidelines)
  • smoking
  • ? Tight fitting briefs in men (elevated scrotal temp?)
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13
Q

How can you reassure someone trying to conceive about the effectiveness of natural conception?

A
  • 80% of couples will be pregnant after 12 cycles (1 year)
  • of those who have not conceived after 12 cycles, about 50% will conceive after a second year of attempted conception (90% overall after 2 years)
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14
Q

What general advice would you give to a couple who is trying to conceive?

A
  • regular intercourse 2-3 times a week
  • don’t recommend temp charts, LH detection devices, intercourse around time of ovulation as can put added strain on couple
  • modifiable risk factors = smoking, alcohol, drug use and weight
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15
Q

What pre-conception also advice is given to a couple who are TTC?

A
  • folic acid
  • rubella status +/- immunisation
  • cervical check
  • control of chronic illness (eg DM, epilepsy, stopping any teratogenic meds
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16
Q

What questions do you ask in the female history when investigating fertility?

A
  • age
  • past pregnancies
  • types of contraception previously use and when stopped
  • Sx suggesting ovulatory problems = menstrual disturbance, galactorrhea, hirsutism, acne, weight, stress, thyroid disease
  • Sx suggesting tubal, uterine, cervical factors = PID, STIs, abdominal/pelvic surgery, IMB, PCB, smear history, dyspareunia, dysmenorrhea (endometriosis)
  • past med Hx = thyroid disease, DM, CF
  • meds incl chemo
  • lifestyle factors = smoking, alcohol intake, drugs
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17
Q

Why can CF impact fertility in a woman?

A

Thicker cervical mucus

Ovulation problems

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18
Q

What questions do you ask as part of male history when investigating fertility?

A
  • weight
  • previous children with other partners
  • Hx suggesting 1* spermatogenic failure - history of genital tract infections (eg mumps orchitis, prostatitis, STIs), surgery or trauma to male genital/inguinal region, previous urogenital abnormality (eg undescended testis)
  • sexual = ejaculatory or erectile dysfunction
  • past med hx = neoplasia, DM, CRF, Thyrotoxicosis, CF
  • meds incl chemo
  • exposure to lead, cadmium, radiation
  • lifestyle factors = alcohol, smoking, drug use, stress, social or occupational situations that may cause testicular hyperthermia
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19
Q

What questions should be asked of both the male and female when investigating fertility?

A
  • previous pregnancies together or with other partners
  • length of time trying to conceive
  • frequency of intercourse
  • difficulty/discomfort with intercourse
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20
Q

What should be looked at as part of the female exam when investigating fertility?

A
  • general examination
  • BMI
  • 2* sexual characteristics
  • galactorrhea (hyperprolactinaemia)
  • hirsutism/acne (PCOS)
  • pelvic exam
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21
Q

What should be looked at while doing a male examination when investigating fertility?

A
  • general exam
  • BMI
  • assessment of 2* sexual characteristics (eg sexual hair, build (decreased in hypogonadism)
  • gynaecomastia (hypogonadism)
  • scrotal exam - lumps (cancer, varicocele, hernia), small soft testes (hypogonadism), undescended testes
  • penis exam = position of urethral meatus
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22
Q

When can semen analysis be done?

A

After 3 days of abstinence

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23
Q

How should semen be collected for semen analysis?

A
  • collect in sterile plastic container after masturbation
  • analysed within 1-2 hrs
  • if abnormal repeat in 12 weeks
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24
Q

What should be done if semen analysis comes back as abnormal?

A

Repeat after 12 week

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25
What should be done if semen analysis comes back as azoospermia?
Repeat immediately
26
What is azoospermia?
No sperm present
27
What is oligospermia?
<15 million/ml
28
What is severe oligospermia?
<5 million/ml
29
What is asthenospermia?
Absent of low motility
30
What is teratozoospermia?
Excessive number of abnormally formed sperm
31
What are the normal parameters of a semen analysis?
32
What is the difference between aspermia and azoospermia?
Aspermia = a lack of semen Azoospermia = no sperm within the semen
33
What are some other factors that can be looked at outside of the normal semen analysis?
MAR test: mixed agglutination reaction: abs to sperm in blood, cervical mucus or semen. Steroids/IUI/IVF as tx. Liquefaction time: complete in 30-60 mins Vitality> 75% of sperm alive
34
What are potential causes of abnormal semen analysis? (10)
* idiopathic oligospermia & asthenozoospermia - infections - epididymitis, orchitis - radiotherapy - cryptorchisism - CF (congenital absence of vas deferens) - varicocoele (? Why impairs fertility) - surgery (retrograde ejaculation after TURP) * endocrine: raised PRL, kallmann’s syndrome, diabetes * antisperm Abs (esp after reversal of vasectomy) * klinefelters syndrome (normal intellect, small testes, infertile)
35
What investigations would you do for abnormal semen analysis? (What labs for azoospermia)
* exam scrotum * labs: in azoospermia = FSH, LH, testosterone, prolactin, TSH +/- karyotype
36
What management can be done for mild-moderate oligospermia?
Intrauterine insemination
37
What management can be done for moderate to severe oligospermia?
IVF
38
What management can be done for severe oligospermia?
Intracytoplasmic sperm injection - IVF
39
What management can be done for azoospermia?
Surgical sperm retrieval (+ ICSI-IVF) Donor sperm
40
What are hypothalamic causes of ovulation failure? (5)
* stress * altered BMI (include anorexia) * exercise * drugs (exogenous gonadotrophins) * kallmanns syndrome (genetic failure of GnRH production)
41
What thyroid issue can cause ovulation failure?
Hypo & hyperthyroid
42
What pituitary issues can cause ovulation failure? (3)
* Hyperprolactinaemia * tumours * Sheehan’s syndrome
43
What adrenal issues can cause ovulation failure?
* Cushing’s syndrome * CAH
44
What ovarian issues cause ovulation failure? (4)
* **PCOS** * premature ovarian failure * gonadal dysgenesis (ovary imperfectly formed due to abnormalities of X chromosome) * luteinized unruptured follicle syndrome
45
What pancreas issue can cause ovulation failure?
Uncontrolled diabetes
46
What can be sued to aid detection of ovulation?
* history: - regular cycles - vagina spotting, discharge, pelvic pain (mittelschmerz) at time of ovulation * examination generally not done * body temp drop 0.2*C pre ovulation and rise 0.5*C post ovulation
47
What investigations can be done to detect ovulation?
* mid luteal progesterone - D21 progesterone of 28 day cycle (or menstruation -7) * u/s = follicule growth and corpus luteum development * OTC urine kits - check LH surge * analysis of cervical mucus
48
What tests might be done to check for ovulation failure?
* FSH, LH, oestradiol (day 2-4), TFTs, prolactin, testosterone, SHBG, AMH * mid luteal progesterone
49
How might AMH indicate what the cause of ovulation failure is?
Normal AMH: 1.5-4ng/ml: high in PCOS, low in ovarian failure
50
What is not recommended for testing for ovulation failure?
* basal body temp charts * use of ovulation predictor kits
51
What else is PCOS called?
Stein-Leventhal syndrome
52
What are the hallmark features of PCOS?
* polycyclic ovary (20%) - 12 or more follicles (small immature, no dominance) Or * an enlarged ovary >10ml
53
What are the diagnostic features of PCOS (5%)?
2 out of 3 of: * PCO on u/s * irregular periods (>35 days or 6-9 menses/year) * hyperandrogenism: clinical (acne, hirsutism) or biochemical (raised testosterone)
54
How does PCOS appear on u/s?
String of pearls appearance
55
What are the non-medical ways to manage PCOS?
lifestyle = smoking cessation, weight loss
56
What are the medical ways to handle PCOS?
* clomiphene * metformin * gonadotrophins * laparoscopic ovarian diathermy
57
What is the pathology underlying PCOS?
Genetic and environmental (body weight) factors Disordered LH production and insulin resist-hyperinsulinaemia
58
What pathology causes PCOS?
**increased androgens** * raised LH and hyperinsulinameia lead to increased ovarian and adrenal androgen production * hyperinsulinaemia leads to decreased SHBG production which increases free androgen Results in: * disruption of folliculogenesis - ovarian follicles & irregular or absent ovulation * clinical hyperandrogegism - hirsutism and acne
59
What are the clinical features of PCOS?
* Presentation can vary * miscarriage, infertility, type 2 diabetes, endometrial cancer
60
What is the rate of diabetes with PCOS?
* up to 50% T2DM * 30% GDM
61
Why does PCOS increase the risk of endometrial cancer?
Unopposed estrogens - need at least 3-4 bleeds/year to protect endometrium
62
What lab investigations would you do for PCOS? (6)
* FSH (n) * LH (>10IU/L) * prolactin (n/mildly raised = 25-40) - greatly raised 500-800 think tumour * TSH (n) * testosterone (>2.5nmol/L and <4.8nmol/L) - note if way higher think of CAH or androgen secreting tumour * can also use LH:FSH ratio 3:1
63
What other investigations would you do for suspected PCOS?
* U/S = TVUS * screening for diabetes and hyperlipidaemia
64
What are the 2 approaches to management of PCOS?
* symptoms * fertility
65
How can the symptoms be managed in PCOS?
* diet and exercise (all symptoms) lower insulin * **COC** (menstruation & hirsutism) regular period suppresses ovarian androgen production increases SBHG production can worsen insulin resistance * **metformin** (promotes ovulation, treat hirsutism) insulin sensitiser * **antiandorgens** (hirsutism) **cyproterone acetate (Diane-35)** **spironolactone** * **topical eflornithine** (hirsutism)
66
How is the induction of ovulation done in cases of PCOS?
* lifestyle = smoking cessation, restoration of normal weight * treat specific causes = thyroid and hyperprolactinaemia * medications to specifically induce ovulation or other methods
67
What methods are spefically used to induce ovulation in PCOS?
* clomifene * metformin * laparoscopic ovarian diathermy * gonadotrophins
68
How is Clomifene given to induce ovulation in PCOS?
50mg/day Day 2-6 of cycle Limited to 6 months
69
What is Clomifene?
Non-steroidal, antioestrogenic (SERM)
70
How does Clomifene work to induce ovulation in PCOS?
Blocks negative feedback therefore high FSH/LH (Only an agonist when the prevailing levels of oestrogen are very low: otherwise an antagonist)
71
How must a patient be monitored while taking Clomifene?
TVUS (at least first cycle) * ovarian response * endometrial thickness (can thin as anti-estrogen)
72
What is the success rate of Clomifene?
* ovulation rate 70% * live birth rate 40% * multiple pregnancy 10%
73
How is dose escalation done for Clomifene?
100mg or 150mg
74
How does metformin induce ovulation?
* insulin sensitiser * promotes ovulation * can be used alone or in combo with Clomiphene (in clomiphene resistant ladies)
75
What are the advantages of metformin as a way to induce ovulation in PCOS?
Nil risk of multiple pregnancy Treats hirsutism ? Continue into pregnancy to lower GD and miscarriage
76
How do you carry out laparoscopic ovarian diathermy?
Each ovary, few points, few seconds
77
When are Gonadotrophins used to induce ovulation?
* human recombinant FSH +/- LH or purified urinary if failure of clomiphene or hypothalamic problem * when follicle reaches correct size (~17 mm) stimulate ovulation with HCG or recombinant LH
78
What are some of the complications of ovulation induction?
* multiple pregnancies * ovarian hyperstimulation syndrome (OHSS)
79
What is this?
OHSS
80
What is this?
Ovarian hyper stimulation syndrome (OHSS)
81
What can cause OHSS?
Gonadotrophin (and rarely clomiphene) overstimulate the follicles which can get very large and painful
82
How can OHSS be prevented?
Lowest effective dose, monitor follicles with u/s (withdraw GN if excessive growth)
83
What causes OHSS?
Leakage of fluid from intravascular space to third space
84
What is seen in severe cases of OHSS? (6)
* hypovolaemia * electrolyte abnormalities * ascites * pulmonary oedema * thromboembolism
85
What do you admit the patient with OHSS for?
* IVF * electrolyte monitoring * fluid drainage * thromboprophylaxis
86
What factors may prompt earlier referral of a woman with fertility issues?
* age >35 yrs * amenorrhea/oligomenorrhea * previous abdominal/pelvic surgery * previous PID * previous STI * endometriosis * abnormal pelvic exam * significant systemic illness (eg DM, renal disease) * known reason for infertile (eg prior treatment for cancer)
87
What are some causes of failure of gamete transfer or embryo transport?
* tubal blockage: - infection (PID, IUD) - endometriosis - ectopic pregnancy - surgery/adhesions *uterine: - leiomyomas (fibroids): if large enough to distort the uterine cavity or block the tubes - intrauterine adhesions (ashermans syndrome) * cervical problems: - antisperm antibodies - problems a/w/ cervical/vaginal infections - prev cone biopsy * sexual: - impotence - dyspareunia (eg endometriosis)
88
What investigations can be done for tubal patency?
* hysteroscopy, Lap and Dye: methylene blue * hysterosalpinogram/HyCoSy: radio-opaque contrast - may miss endometriosis and lateral adhesions
89
What treatments may be done for tubal issue in fertility?
Tubal surgery: - adhesinolysis - salpingostomy +/- assisted conception
90
What treatments are done for cervical problems causing fertility issues?
* ? Steroids if ASA * IUI * IVF
91
What treatment is done for impotence causing fertility issues?
Psychosexual counsellor

OBGYN (25 decks)

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