Fertility and Subfertility Flashcards
When should investigations begin for infertility?
After couple has been trying to conceive without success for 12 months
Can be reduced to 6 months if woman is older than 35, as ovarian stores are likely to be already reduced and time is more precious
Causes of infertility
Sperm problems (30%) Ovulation problems (25%) Tubal problems (15%) Uterine problems (10%) Unexplained (20%)
40% of infertile couples have a mix of male and female causes
General advice for couples trying to conceive
Woman should be taking 400mcg folic acid daily
Aim for a healthy BMI
Avoid smoking and drinking excessive alcohol
Reduce stress as this may negatively affect libido and the relationship
Aim for intercourse every 2-3 days
Avoid timing intercourse
Initial investigations for infertility (primary care)
BMI (low could indicate anovulation, high could indicate PCOS)
Chlamydia screening
Semen analysis
Female hormonal testing
Rubella immunity in the mother
Female hormone testing
Serum LH and FSH on day 2 to 5 of the cycle
Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle).
Anti-Mullerian hormone
Thyroid function tests when symptoms are suggestive
Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea
Further investigations in female infertility (secondary care)
Ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus
Hysterosalpingogram to look at the patency of the fallopian tubes
Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis
Management of anovulation as the cause of infertility
Weight loss for overweight patients with PCOS can restore ovulation
Clomifene (or letrozole) may be used to stimulate ovulation
Gonadotropins may be used to stimulate ovulation in women resistant to clomifene
Ovarian drilling may be used in polycystic ovarian syndrome
Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)
Management of tubal factors in infertility
Tubal cannulation during a hysterosalpingogram
Laparoscopy to remove adhesions or endometriosis
IVF
Management of uterine factors in infertility
Surgery may be used to correct polyps, adhesions or structural abnormalities affecting fertility
Management of spermal factors in infertility
Surgical sperm retrieval if blockage along the vas deferens preventing sperm from reaching ejaculated semen
Surgical correction of obstruction in the vas deferens
Intra-uterine insemination
Intracytoplasmic sperm injection (ICSI) (significant motility issues, a very low sperm count and other issues with the sperm)
Donor insemination with sperm from a donor
Collection of sperm sample
Abstain from ejaculation for at least 3 days and at most 7 days
Avoid hot baths, sauna and tight underwear during the lead up to providing a sample
Attempt to catch the full sample
Deliver the sample to the lab within 1 hour of ejaculation
Keep the sample warm (e.g. in underwear) before delivery
Pre-testicular causes of sperm abnormalities
Pathology of the pituitary gland or hypothalamus
Suppression due to stress, chronic conditions or hyperprolactinaemia
Kallman syndrome
Testicular causes of sperm abnormalities
Mumps
Undescended testes
Trauma
Radiotherapy
Chemotherapy
Cancer
Klinefelter syndrome
Y chromosome deletions
Sertoli cell-only syndrome
Anorchia (absent testes)
Post-testicular causes of sperm abnormalities
Damage to the testicle or vas deferens from trauma, surgery or cancer
Ejaculatory duct obstruction
Retrograde ejaculation
Scarring from epididymitis, for example, caused by chlamydia
Absence of the vas deferens (may be associated with cystic fibrosis)
Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)
Initial investigations after abnormal semen analysis
History
Examination
Repeat sample
USS testes
