Fertility and subfertility Flashcards
Define subfertility
Couple are subfertile if conception has not occurred after a year of regular unprotected intercourse
Prevalence of subfertility
15%
Define infertility
Inability to concieve
Difference between primary and secondary subfertility
Never conceived vs conceived even if miscarriage/termination
What are the 4 conditions required for pregnancy?
1) Egg must be produced
2) Adequate sperm release
3) Sperm must reach egg
4) Fertilized egg must implant
What are the contributors to sub-fertility and their %
Ovulatory problems 30% Male problems 25% Tubal problems 25% Coital problems 5% Cervical problems <5% Unexplained (implantation?) 30%
Why does fertility decline with age?
Reduced genetic quality of remaining oocytes
What is mittelschmertz
Vaginal spotting, discharge or pelvic pain around ovulation
Clinical evidence of preovulation
1) Elevated serum progesterone in mid luteal phase (7days before menses)
2) Over the counter urine predictor kits shows LH surge
Fun scientific evidence of preovulation
Cervical mucus- fernlike patterns formed on dry slide and spinnbarkeit strings upto 15cm.
body temp drops 0.2 rises 0.5 in luteal
Define Polycystic ovary
Multiple small follicles in an enlarged ovary with regular cycles
Diagnostic criteria for Polycystic ovarian syndrome
2/3 criteria
1) PCO on US
2) Irregular periods >35d/ 5 weeks or more apart
3) Hirsutism: clinical (acne/excess body hair) or biochemical (increased testosterone)
Presentation of PCOS
Oligo/amenorrhoea, hirsutism, acne, obesity, increased rates of miscarriage, subfertility
How would you investigate for PCOS
FSH, LH, testosterone, prolactin, TSH
Fasting lipids and glucose
TVS«
Differentials for Anovulation (5)
Hypothalamic disease- low FSH Ovarian failure- high FSH PCOS- normal FSH Prolactinoma- Thyroid problems
Complications of PCOS (3)
Type 2 diabetes in 50%
Gestational diabetes 30%
Endometrial cancer (unopposed oestrogen)
Treatment of PCOS symptoms
Cant treat subfertility Advice to reduce weight COCP but neet 3-4 bleeds to protect endometrium Anti-androgens used for hirsutism Cyproterone acetate/Spironolactone Metformin-insulin sensitizer Eflornithine- topical,
Hyperprolactinaemia can be caused by (4)
Pituitary adenomas/hyperplasia
PCOS
Hypothyroidism
Psychotropic drugs
How do you treat prolacinomas
Bromocriptime/cabergoline- dopamine agonists- restores ovulation because dopamine inhibits prolactin release
Surgery if fails
Firstline treatment of PCOS and induction of ovulation by _, which is a _.
Clomifene 6 months days 2-6 antioestrogen blocking receptors in the hypothalamus and pituitary
Secondline treatment for PCOS
Lifestyle and weight loss
Clomifene then…
1) Metformin-oral insulin sensitizing restores ovulation
2)Gonadotrophins- daily subcut recombinant urine purified FSH+/-LH with LH surge/bhCG after a 17mm follicle develops. Give if weight normal.
3) Laproscopic ovarian diathermy- each ovary is monopolar diathermied at a few points for a few seconds + checked for all other pathologies
4)GnRH pump
5)IVF
Firstline ovulation treatment gives ovulation rate and live birth rates of
70% 40% (bad effect on endometrium)
How is follicular growth monitored after admin of all these therapies?
US
What are the side effects of ovulation induction
Multiple pregnancies
Ovarian hyperstimulation syndrome
Ovarian and breast carcinoma
