Sub-fertility Flashcards
1
Q
Define Sub-fertility.
A
A woman of reproductive age that has not conceived after 1 year of regular, unprotected sexual intercourse.
- Chances of getting pregnant 19-26yo = 98% over 24 months with twice weekly unprotected sexual intercourse
- Sub-fertility affects 1 in 6 couples - increases with maternal age
2
Q
What percentages of sub-fertilities are done to men and women?
A
- Female problem = 30-40%
- Unexplained = 30%
- Male problem = 25-30%
3
Q
What are the causes of female sub-fertility?
A
- Hypothalamic-pituitary failure
- Low gonadotrophins and low oestrogen
- Low weight,xcessive exercise
- Kallman’s syndrome, Sheehan’s syndrome
- Hypothalamic-pituitary-ovarian dysfunction
- Normal gonadotrophins, normal oestrogen
- PCOS
- Ovarian Failure
- High gonadotrophins, low oestrogen
- POI
- Prolactinaemia, Thyroid Disease
- Tubal disorders (infections, adhesions, endometriosis, congenital, salpingectomy)
- Cervical and uterine factors (uterine abnormalities, fibroids)
- Genetic/developmental (chromosomal abnormalities/genetic issues)
- Lifestyle/functional (smoking, method of sex)
4
Q
What are the causes of male sub-fertility?
A
- Structural - cryptorchidism, absence of vas deferens in CF, varicocele
- Hypothalamic/Pituitary - hypothalamic hypogonadism, hyperprolactinaemia
- Functional - erectile dysfunction
- Pharmacological - recreational drugs
- Infectious - epididymitis, mumps orchitis
- Lifestyle - ETOH, smoking, BMI >30
- Genetic - Klinefelter’s XXY, Kallman’s, testicular feminisation
5
Q
What are the appropriate investigations for sub-fertility?
A
- Full history
- Duration and type of infertility
- Coital frequency
- Menstrual history
- PCOS symptoms
- Contraceptive history
- Previous STI
- PMHx, PSHx, DHx, SHx
- 1st line basic tests
- Male:
- Semen analysis (2 tests, 3m apart) → if azoospermia, most commonly due to varicocele
- Chlamydia screen
- Female:
- Mid-luteal (day 21) progesterone (confirm ovulation) → >30 indicated ovulation
- Adjust if cycle >28 days
- If POI, you cannot do this
- Chlamydia screen
- Prolactin, TFTs, progesterone (prolonged irregular cycles), LH/FSH (irregular cycles)
- Mid-luteal (day 21) progesterone (confirm ovulation) → >30 indicated ovulation
- Male:
- Ovarian reserve measure (≥1 of 3 results measures around day 3 of the cycle)
- FSH → raised; inaccurate during the luteal phase (being supressed by progesterone)
- Anti-Mullerian hormone → low
- TVUSS → Antral Follicle Count (<4 = poor response; 16+ = good response)
- Tubal assessment
- No co-morbidities → hysterosalpingography to assess patency
- Co-morbidities (Hx of PID, ectopics, endometriosis) → laparoscopy and dye
6
Q
What is the management of unexplained sub-fertility?
A
- Unexplained sub-fertility or Mild endometriosis or ‘Male factor’ = try for another 12m
- After this, you can consider IVF
7
Q
What is the medical management of sub-fertility?
A
- Ovulation induction → anovulation (PCOS, idiopathic)
- 1st line: clomiphene (blocks oestrogen-R → increased LH/FSH release)
- 2nd line: FSH and LH injections
- 3rd line: pulsatile GnRH or DA agonists
8
Q
What is the surgical management of sub-fertility?
A
- Laparoscopy - adhesions, ovarian cyst, endometriosis
- Myomectomy - fibroids
- Tubal surgery - blocked tubes amenable to repair
- Laparoscopic ovarian drilling - PCOS (unresponsive to medical management)
- Removes endometrium to reduce amount of androgen-producing tissue
9
Q
Describe assisted conception?
A
- Intrauterine insemination ± LH/FSH
- IVF
- Intracytoplasmic sperm injection (ICSI)
- Donor insemination ± LH/FSH
- Donor egg with IVF
10
Q
What are the indications for intrauterine insemination?
A
- Idiopathic
- Anovulation unresponsive to OI
- Mild male factor
- Minimal to mild endometriosis
11
Q
What are the indications for IVF?
A
- Blocked tubes
- Male minor factor
- Idiopathic
- Unsuccessful OI or intrauterine insemination
12
Q
Who is available for IVF?
A
- Decided trust-by-trust (postcode lottery) – NICE guidance
- Women <40 offered 3 cycles of IVF if:
- Subfertility for 2 years
- Not pregnant after 12 cycles of artificial/intrauterine insemination
- Women 40-42 offered 1 cycle of IVF if:
- Subfertility for 2 years and/or not pregnant after 12 cycles of AI
- Never had IVF
- No evidence of low ovarian reserve
- Informed about additional implications of IVF at this age
- Women <40 offered 3 cycles of IVF if:
13
Q
What are the indications for intracytoplasmic sperm injection?
A
- Oligospermia
- Poor fertilisation - DM, erectile dysfunction
- Most common treatment for male infertility
14
Q
What are the indications for donor insemination?
A
- Azoospermia
- Single women
- Same sex couples
- Infectious disease
15
Q
What are the indications for donor egg with IVF?
A
- POI
- Bilateral oophorectomy
- Gonadal dysgenesis
- High-risk generic disorder
