Tutorial 13: Infertility Flashcards
What is the definition of Infertility?
Failure to conceive after 12 months of unprotected intercourse
What are the two types of infertility?
Primary Infertility: Couple who has never been able to conceive.
Secondary Infertility: Couple who find it difficult to conceive having already conceived in the past (could have had a term pregnancy or may have experienced miscarriage).
What is Fecundity?
Fecundity is the capacity to conceive and is measured as the monthly probability of conception.
Average monthly chance of conceiving in normal fertile couples is 20%.
Average duration for fertile couple to conceive is 3 months.
Age dependent.
What lifestyle factors effect Fecundity?
– Smoking (damages eggs, fallopian tubes, sperm, affects hormones in men/women, miscarriage risk, ectopic pregnancy)
– Moderate/heavy EtOH (age dependent)
– Weight (over/under – affects ovulation)
– Exercise (none or excessive)
– Medication - steroids
What are the most common causes of infertility, in descending order?
Infertility- 1/6 couples failing to conceive
- 33% male factors
- 20% anovulation
- 15% tubal factors
- 10% endometriosis
- 5-10% cervical factors
- 15% unexplained (includes stress & environmental factors)
What are causes of infertility in a woman?
Anovulation
- premature ovarian failure
- PCOS
- hypothalamic/pituitary insufficiency
- hyperprolactinaemia
- metabolic disease (thyroid, renal, liver, underweight or obese)
Tubal factors
- PID (1 episode 10%, 3 episodes 50%) o previous ectopic pregnancy
- adhesions, endometriosis
- peritoneal infections
Cervical factors
- congenital, infection, post-surgery
What Hx and Ex would you do for Infertility?
History
- General - Age, occupation/environment, folate in diet, smoking, drugs and EtOH
- Specific symptoms – acne, hirsutism, dysmenorrhoea etc
- Intercourse – timing (in relation to ovulation) and frequency (>2 x per month)
- Menstrual history
- Past obstetric history (pregnancies, miscarriages)
- Contraception
- Gynaecological history
Examination
- General inspection
- Height, weight, BMI
- Vitals: HR, BP, RR, Temp (incr 0.3oC post-ovulation), Sa02
- Endocrine/systemic disease – including PCOS (evidence of hirsutism, acne, and alopecia)
- Abdomen: shape, scars, tenderness
- Pelvis (with chaperone/ supervisor):
- External genitalia
- Speculum – Cervix
- +/- smear, pipelle, HVS/endocx swab
- Bimanual – uterine size, tenderness, adnexal masses
What Investigations would you do for a female with infertility?
- Infective Screen: hepatitis, rubella, chlamydia, and gonorrhoea
- Hormones:
- Progesterone (mid luteal rise > 30mmol/L in 3 cycles)
- Testosterone
- LH (elevated days 2-5)
- FSH
- LH:FSH ratio (elevated in PCOS)
- Thyroid (hypothyroidism)
- Prolactin (produced by pituitary, increased levels interferes with ovarian function)
- USS: View follicle development or change to secretory endometrium.
- Laparoscopy/hysterosalpingogram: Assess tubal patency
What are causes of infertility in a male?
Sperm
- abnormal spermatogenesis (2° to mumps, orchitis, chromosomal abnormalities, chemical/radiation exposure)
- oligospermia/azoospermia
- abnormal morphology or motility
Anatomical
- congenital
- obstruction of vas deferens
- varicocele (varicosities in spermatic cord veins)
- 2° to infection (mumps, STIs, prostatitis)
- surgery or trauma
Endocrine
- hyperprolactinaemia
- hypothalamic or pituitary failure (tumour, radiation or surgery)
- exogenous androgens
- adrenal hyperplasia
Sexual dysfunction
What Hx and Ex would you do for a male with infertility?
History
- Intercourse – frequency
- Erection/ejaculation problems
- Pubertal development
- Previous fatherhood
- Previous STI
- Previous surgery – especially GU tract
- Social- smoking, EtOH, environmental toxins, illicit drug use
Examination
- Evidence of gynaecomastia, eunuchoidal features (testes are present but fail to function normally; may be of gonadal or pituitary origin)
- Secondary sexual characteristics
- Genital examination
- Particularly testicular volume/size
- Vas deferens palpation
What Investigations would you do for a male with infertility?
Semen analysis
- volume > 2 mL
- density > 20 mil/mL
- motility > 50%
- normal morphology > 70%
Blood Tests
- FSH (1o testicular failure, pituitary dysfxn)
- Testosterone + LH (androgen deficiency)
- Karyotyping (exclude chromosomal abnormality)
Others- swabs for chlamydia and Gonorrhoea, post-coital test (>20 motile sperm/HPF)
What general management would you do for infertility?
Depends on aetiology
General Measures
- Coital timing
- Every 2 days in peri-ovulatory period, days 12-16
- Emotional support
- Lifestyle factors
- Smoking cessation, weight loss (BMI 19-25), healthy diet, caffeine reduction
What specific treatment measures would you do for infertility?
PCOS
- weight loss
- clomiphene citrate (anti-oestrogen, increases FSH in early follicular phase)
- Metformin (improves insulin sensitivity)
- Recombinant FSH (direct ovarian stimulation, risk of multiple pregnancy)
Tubal disease: Hysterosalpingogram, manual removal or balloon tuboplasty, IVF if severe
Endometriosis – IVF
Male factors
- Intrauterine insemination (IUS)
- Intracytoplasmic injection ( ICSI)
Idiopathic: Empiric clomiphene, IVF, IUI
What is the Diagnostic criteria for PCOS?
Disorder of hypothalamo-pituitary-ovarian axis characterised by raised LH and testosterone in 50% of cases.
Diagnostic Criteria (>2 of following)
- Evidence of oligo or anovulation
- Clinical and/or biochemical evidence of androgen excess
- Ultrasound evidence of polycystic ovaries
- Enalrged ovaries
- Ring of follicles in the periphery
- Stromal hypertrophy
What are the signs and symptoms of PCOS?
Common:
- Menstruation irregularities (75%)
- Overweight (30-80%)
- Hirsutism (60% of women with PCOS)
- Acne (15-25%)
- Hypertension
- (Affecting women of reproductive age)
Uncommon:
- Scalp Hair Loss
- Oily skin or excessive sweating
