T2 L7:L7 (Theme 2): Causes and Treatments of Subfertility Flashcards
what are the requirements for conception ?
- Progressively motile normal sperm capable of reaching and fertilizing the oocyte.
- Timely release of a competent oocyte.
- Free passage for the sperm to reach the oocyte and for the embryo to reach the uterus.
- A mature endometrium that allows implantation.
What is infertility
Inability to conceive after 2 year of frequent unprotected intercourse
NICE:““If a woman has not conceived after a year, offer further clinical assessment and investigation, along with her partner”
what are the causes for infertility
Unexplained 30%
Ovulatory 27%
Male factor 19%
Tubal 14%
Endometriosis 5%
Other factors 5% (uterine, endometrial, gamete or embryo defect)
what are the indications for early referral for a female
Female:
Aged over 35 years
Amenorrhoea/oligomenorrhoea
Previous abdominal/pelvic surgery
Previous PID/STD
Abnormal pelvic examination
what are the indication for early referral for males
Previous genital pathology (history of testicular maldescent, surgery, infection or trauma, there is a greater incidence of abnormal semen parameters)
Previous STD
Significant systemic illness
Abnormal genital examination
what are the reasons for an abnormal Semen analysis (SA)
No reason in 50%
try testicular failure is the commonest cause for oligo/azoospermia
Obstructive or non-obstructive azoospermia FSH, LH & T
Y chromosome microdeletion & cystic fibrosis if sperm count < 5 million
what is the most important facto for fertility
Females Age:
-A woman’s fertility declines with age
This is due to the decline in oocyte number and quality rather than uterine receptivity
The increased rate of chromosomal abnormalities in the oocyte also results in higher aneuploidy and miscarriage rates
what tests do you use to assess females
Screen for chlamydia & Rubella
Ovarian reserve
Early follicular phase hormone level (FSH, LH & E2)
AMH (Anti-Mullarian Hormone)
AFC (Antral Follicle Count)
Ovulation test
Tubal test
describe the female ovary and follicular development
In the female AMH is first produced by the granulosa cells of the early growing follicle
(preantral and small antral stages – when <4mm), and it continues to be produced by the granulosa cells of growing follicles up until the early antral stage whereupon it declines precipitously – once they reach 8mm in diameter by this time almost no AMH is made.
1-Primordial follicles (prophase 1)-2- antral follicles- maturing follicles -pre-ovulatory follicle
describe the AMH (anti-mullarian hormone ) and what its levels indicate
Produced by the Granulosa cells of pre-antral and small antral stages
Levels of AMH constant through monthly periods but declines with age
Higher AMH levels predict a good response
Lower AMH levels predict a poor response
what is the Mid-luteal P4>30nmol/l accepted as
& what is follicular tracking used for
evidence of ovulation
what are the diseases of ovulation
PCOS commonest cause of anovulation and 1ry or 2ry oligo/amenorrhea
If oligo/amenorrhea FSH/LH, E2, prolactin, TFT, androgens & SHBG
85% PCO (normal FSH/LH & E2)
5% POF (high FSH & low E2)
10% hypogonadotrophic hypogonadism (low FSH & low E2)
Describe tubal patency
Disease can be proximal (25%) or distal (75%)
PID 2ry to chlamydia is the commonest cause of tubal damage
Risk of tubal damage is about
12% after one episode of pelvic infection,
23% after two episodes, and
54% after three episodes
Other causes: septic abortion, ruptured appendix, pelvic surgery and ectopic pregnancy
How do you fix tubal patency
1-Hysterosalpingogram (HSG)
Hysterosalpingo-contrast-ultrasonography (HyCoSy)
2-Laparoscopy & dye
If low risk of tubal disease offer HSG or HyCoSy
Chlamydia screening before instrumentation
what are the advantages of HSG
- relatively safe
- ease of use
- Delineation of the uterine cavity and fallopian tubes
what are the disadvantages to HSG
-inability to assess the pelvic peritoneum
what are the disadvantages to Ultrasound and dye
Time consuming
requires training
risks of injury to the patient
what are the uterine abnormalities that can occur
Adhesions, polyps, submucous fibroids and septae
apart from HSG and TVS what is another method that is better for treating abnormality
hysteroscopy
-undoubtedly better than HSG and TVS at detecting abnormalities
How do you induce ovulation
Clomid (Clomifene Citrate) for women who have PCO
Anti-oestrogen effect on hypothalamic pituitary axis
FSH injections for resistant PCO or Hypogonadotrophic Hypogonadism
Risk of multiple pregnancy
Monitor 1st cycle using USS
what are the advantages of IUI/OI/TSI treatment
LESS STRESS
LESS INVASIVE
LESS TECH
CHEAP
success rate:10% per cycle
NICE guidelines for IUI
Do not offer IUI for couples who have unexplained infertility
IUI for single women, same sex couple or heterosexual couple who have problem with intercourse
IVF for couples who have unexplained infertility
when is IVF needed
Tubal damage
Low sperm quality
Unexplained infertility
Low ovarian reserve
look at slides for pics
how did it go?
