Week 5 lectures on infertility management Flashcards
What is anovulation?
Absence of ovulation.
What is anovulation associated with?
Oligo/amenorrhoea
What stimulates endometrial thickening?
FSH and oestrogen
What do ovulation predictor kits test for?
The surge in LH 36 hours before ovulation.
Where is oestrogen secreted from?
The developing follicle in the ovaries, the adrenal cortex and the placenta during pregnancy
What is indicative of normal ovulation?
Regular 28-35 day cycles.
Confirm this by a mid luteal serum progesterone (>30nmol/L) in 2 separate samples.
Why would you test for progesterone in the luteal phase to indicate ovulation?
Indicates that ovulation has passed and now the follicle has become the corpus luteum and is secreting progesterone.
How would you treat hypogonadotrophic hypogonadism?
Pulsatile GnRH release- either subcutaneously or pump IV
Gonadotrophin daily injections (FSH and LH)
What monitoring needs to be done in the treatment of hypogonadotrophic hypogonadism?
Ultrasound monitoring for response.
What drug therapy can increase ovulation?
Clomefine citrate is an antioestrogen.
If the first line drug therapy doesn’t work, what other drug therapies/procedures can help ovulation?
Metformin- decreases resistance to insulin. Also decreases androgen production.
FSH and LH daily injections
Laparoscopic ovarian drilling.
What are the risks associated with ovulatory treatment?
Ovarian hyperstimulation- can vary from mild to severe.
Multiple pregnancies
Ovarian cancer.
When are you at increased risk of developing side effects of ovulatory treatment?
When you are over the age of 35.
PCOS
Symptoms of ovarian hyperstimulation
Mild- mild abdominal pain, ovaries greater than 8cm in size.
Moderate- abdominal pain, nausea +/- vomiting, ascites Ovarian size 8-12cm
Severe- clinical ascites, hypoproteinaemia, haematocrit>45%, ovarian size usually greater than 12cm
Critical- haematocrit>55%, oligo/anuria (painful sex), thromboembolism, ARDS
What complications are you more likely to get with multiple pregnancies?
Preeclampsia, gestational diabetes, hypertension, post natal depression
When does your risk of ovarian cancer increase?
If you’ve been using fertility treatments for longer than 12months.
What is twin-twin transfusion syndrome?
Unbalanced vascular communications within the placental bed. Means one child (recipient) develops polyhydramnios (excessive amount of amniotic fluid) and the donor child develops oliguria (abnormally small amounts of waste product), oligohydramnios (not enough amniotic fluid) and growth restriction.
Treatment of TTTS
laser division of the placental vessels, amnioreduction, septostomy.
What are the risks associated with multiple pregnancies for the children?
Low birth weight and prematurity.
What are low birth weight and prematurity linked to in the child?
Low IQ and ADHD.
Short term problems of prematurity
40-60% require neonatal intensive care.
8% need help with breathing.
6% suffer from respiratory distress syndrome
Long term problems of prematurity
In 7.4% of twin pregnancies- one child has a disability e.g. cerebral palsy, congenital heart disease and impaired site.
How does hyperprolactinaemia present?
Amenorrhoea/oligomenorrhoea
Galactorrhoea (excessive or inappropriate production of breast milk)
Raised serum prolactin. Normal FSH and LH however low oestrogen.
Medical treatment of hyperprolactinaemia?
Dopamine agonist.
Define infertility
Failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sex in couples who have not previously conceived.
Primary infertility
Couple have never had children.
Secondary infertility
Couple have previously conceived (however could be failed e.g. miscarriage)
What factors affect fertility?
Age
BMI- 20-30
Intercourse occurring in the six days before ovulation (especially 2 days before)
Alcohol consumption less than 4 units a week.
Non smoker, no recreational drugs
Caffiene should be less than 2 cups of coffee a day
Previous pregnancy makes you more likely
What is infertility due to?
Anovulatory disease- could eb anything from the hypothalamus e.g. anorexia, POF, PCOS, stress
Tubal disease- infective or non infective
Infective tubal disease
Could be pelvic inflammatory disease (chlamydia, gonorrhoea) Transperitoneal spread (appendicitis, intra-abdominal abscess)
Non-infective tubal disease
Endometriosis, surgical (sterilisation), fibroids, polyps, congenital salpingitis isthmica.
What is hydrosalpinx
Distally blocked fallopian tube filled with serous or clear fluid.
Clinical features of hydrosalpinx
Abdominal pain Vaginal discharge Cervical excitation menorrhagia- excessive menstrual blood loss Dysmenorrhoea (painful periods) Infertility Ectopic pregnancy.
What is endometriosis?
Presence of endometrial glands outside of the uterine cavity.
What is the most likely cause of endometriosis?
Retrograde menstruation. Womb lining flows backwards into the fallopian tubes rather than out.
Clinical features of endometriosis
Dysmenorrhoea (painful periods)
dyspareunia (painful sex)
menorrhagia (abnormally heavy periods)
chronic pelvic pain
What will a scan of endometriosis show?
Chocolate cysts.
Male causes of infertility
Hypogonadotrophic hypogonadism e.g. Kallmanns syndrome, anorexia ect
Testicular failure e.g. Kleinfelters syndrome, chemotherapy
Hyperprolactinaemia (macro or micro pituitary adenoma)
Acromegaly
Cushings disease
Hyper or hypothyroidism
Obstructive male infertility
Normal sexual characteristics, normal testicular volume however vas deferens may be absent (CF).
Endocrine features will show normal FSH, LH and testosterone
Non-obstructive male infertility
Low testicular volume, reduced secondary characteristics, vas deferens presents.
Endocrine features- high FSH and LH, low testosterone.
What investigations would you do into male infertility?
History-
Exam- general- look at BMI, hair distribution ect.
Pelvic exam- assess for abnormalities/tenderness/mobility,
What investigations would you do into female infertility
Endocervical swab for mucus Blood check for rubella immunity Cervical smear if due Midluteal progesterone levels (day 21 of a 28 cycle) Test of tubal patency Other tests if indicated e.g. US.
What is a hysterosalpingiogram
Used if there are no risk factors or contraindications for using laparoscopy.
Laparoscopy
Used if suspected pelvic pathology
Hysteroscopy
Only performed in cases with known pathology.
What should a normal semen analysis show
pH- 7.2-7.8 Concentration>15x10^6/ml Motility>50% Morphology>4% WBC<1x10^6
What endocrine tests would you do if semen analysis is abnormal?
Testosterone, FSH, LH, prolactin, thyroid function
Why is rubella a risk in infertility?
Rubella or congenital rubella is a group of physical abnormalities in an infant as a result of maternal infection and subsequent feotal infection.
Symptoms of rubella in a newborn?
Rash at birth Low birth weight Small head size Heart abnormalities Visual problems Bulging fontanelles.
First line, second line and third line management of female infertility
1st line- clomefine citrate or tamoxifen
2nd line- GnRH daily injections
3rd line- laparoscopic ovarian drilling
Treatment of male infertility
Surgery to obstructed vas deferens
Intrauterine insemination in mild disease
Intracytoplasmic sperm injection (sperm injected into egg)
Surgical sperm aspiration from epididymis combined with ICSI
Donor sperm.
Treatment of tubal disease
Tubal surgery to reverse sterilisation
Success depends on amount of healthy tube.
