Subfertility/infertility Flashcards
How many couples have infertility issues?
1 in 7
What % of couples are pregnant within one year and 2 years of trying?
1 year - 80%
2 years - 90%
Infertility
inability to conceive after 12 months of regular intercourse without use of contraception
4 questions you ask yourself with infertility?
are eggs available?
are sperm available?
can they meet?
can embryo implant?
Questions in female history
psychological - duration of infertility - previous contraception - fertility in previous issues - previous pregnancies and complications - menstrual history - medical and surgical history - sexual history - previous investigations
Female examination
abdomen - pelvic - BMI - height - weight - fat and hair distribution - galactorrhoea
What BMI is considered for IVF referral?
under 30
What can galactorrhoea be a sign of?
prolactinoma
Cause of mild hirsutism
PCOS
Causes of severe hirsutism
late onset adrenal hyperplasia
androgen secreting tumour eg adrenal or ovarian
Biochemical measurements used in androgen excess
DHA DHAS SHBG 17-OH progesterone testosterone androsterodione
Clinical measurement of androgen excess and what it looks at
Ferriman Gallwey score
hair on upper lip, face, chest, abdomen
Name one sign of andogen excess
acanthosis nigricans
findings on female pelvic examination of note
tenderness
masses
pelvic distortion
fixed retroversion
3 symptoms of fibroids
pressure symptoms
period problems
infertility
Male history
sexual history - previous investigations and treatment - previous fertility - medical and surgical history - occupational history
Male examination
weight - height - BMI - fat and hair distribution - abdominal and inguinal exam - genital exam
findings/what to look for in genital exam of males
testis varicocoele penis epididymis vas deferens
Causes of epididymitis
STD - chlamydia trachomatis, gonorrhoea, NSTD
What should you think of if small testicular size?
Klinefelters syndrome - 47 XXY
Importance of vas deferens in infertility
CF mutations and congenital bilateral absence of vas deferens
Hypospadias
urethral opening on underside of penis
varicocoele
abnormal torsion and dilation of veins
How to assess man’s sperm
computerised semen analysis
How to determine if eggs are available?
hormonal levels
Usually refer if no pregnancy in 1 year, exceptions to this rule are…
period irregularity PMH testicular problems abnormal testis age HIV/Hep B anxiety
female Age for referral - after trying for how long?
under 35 - 1 year
35-45 - 6 months
rarely refer after 45
Baseline female investigations
rubella immunity
chlamydia
TSH
mid luteal progesterone if regular periods
1-5 day FSH, LH, PRL, TSH, testosterone if irregular
Male baseline investigations
semen analysis
Investigations
Pelvic USS
semen analysis repeat
tubal patency test - HyCoSy
3 parts of PCOS
androgen excess - hirsutism and testosterone
USS polycystic ovaries
infrequent periods - anovulation
How can ovulation be achieved?
clomifene, gonadotrophins, GnRH
What type of medication is clomifene?
selective oestrogen receptor modulator
Dose of clomifene
50mg-150mg day 2-6
If there is amenorrhoea what is important to do if using clomifene?
prime with progestogen
Monitoring of clomifene
follicle scan in 1st cycle
side effects of clomifene
vasomotor and visual
2 reasons for using gonadotrophins for ovulation
no ovulation with clomifene
ovulation but no pregnancy with clomifene
What medication is used for gonadotrophin treatment?
FSH injection for 3-6 cycles
Male factor infertility - what can be used?
ICSI donor insemination intra-uterine insemination IVF surgery eg reversal of vasectomy, surgical sperm retrieval
3 testicular causes of azoospermia
normogonadotrophic
hypogonadism
hypergonadotrophic
3 post-testicular causes of azoospermia
iatrogenic, congenital, infective
Investigations for azoospermia
history and examination
CF screen
FSH,LH,PRL, testosterone, karyotype
2 methods of surgical sperm retrieval
micro epididymal sperm aspiration
testicular sperm extraction
Sexual problems solution
psychosexual counselling
artificial insemination - timed at home or Intra-uterine in clinic
Describe IVF
- eggs harvested from ovary
- eggs fertilised in lab with sperm
- embryos undergo cell division
- Embryos transferred to the womb
Describe ICSI
injection of mature eggs with single sperm
incubate overnight
transfer embryo at day 5
cryopreservation
freezing eggs
Changing society within fertility examples
obesity - lesbian couples - single women - post humous insemination - older women
