Gynaecology: Fertility and the Menopause Flashcards
(39 cards)
At what point is a couple diagnosed as sub-fertile?
Unprotected sex 2-3 times a week for 12 months but still no pregnancy.
Distinguish between absolute and relative sub-fertility?
A person with relative sub-fertility has 1+ factors impeding there ability to get pregnant but that doesn’t mean they won’t get there themselves.
Someone with absolute sub-fertility has 0 chance of getting pregnant without assistance.
Distinguish between primary and secondary sub-fertility?
- Primary = never been pregnant
- Secondary = have been pregnant but have either miscarried or are struggling to conceive again (N.B: if a child came from a previous relationship it still counts as secondary infertility)
What are the 5 things needed for optimum fertility?
- Supply of eggs
- Regular cycle
- Healthy sperm
- Patent Fallopian Tubes
- Receptive Endometrium
Why might someone have a low supply of eggs?
- Lifelong smokers appear to run out of eggs sooner
- Genetic conditions e.g. Turner’s syndrome lead to reduced egg count at birth
- Physical conditions, e.g. having had an ovary removed, naturally reduce egg count.
Why might someone have issues with cycle regularity (causing infertility)?
Mostly PCOS, but also see high BMI induced anovulation, ovarian failure (chemotherapy), hyper-prolactinaemia
Why might someone have issues with Fallopian Tube patency?
Mostly inflammatory or scaring conditions e.g:
- PID (–> tubal occlusion)
- Adhesions
- Endometriosis
- Hydrosalpinx
- Previous ectopic pregnancies
Why might a man have issues with sperm health?
Physical:
- Vasectomy
- Varicocele
- Testicular Torsion
- Orchitis
Genetic:
- Klinefelter’s
- Congenital Bilateral Absent Vas Deferens
Lifestyle choices:
- Overweight
- Alcohol
- Smoking
- Anabolic Steroids
- Emotional stress and depression
Why might someone have issues with a receptive endometrium?
- Fibroids
- Septum
- Polyps
- Asherman’s
What are the standard investigations for a patient with fertility issues?
MOOT(U) (like an MOT):
- Male factors
- Ovulation
- Ovarian reserve
- Tubal patency
- Uterine cavity
How are Male factors investigated in a fertility setting?
Semen analysis twice in the span of 3 months:
- mainly look at count, volume, pH, vitality, motility, and morphology
- if grossly abnormal send for further testing (e.g. karyotyping), FSH and LH
How are ovulation factors investigated in a fertility setting?
- Regularity of cycle
- Urinary LH
- Mid luteal phase progesterone (7 days before end of cycle)
These factors combined give a good impression of ovulation vs e.g. menopause
Why is progesterone always measured 7 days before the next period is expected?
Ovulation always occurs 14 days before end of cycle, progesterone rises midway through this (so 7 days before end of cycle); reliable point where all women will have raised progesterone (unless there’s an issue)
Essentially doing it this way prevents you getting false negatives related to natural variations in women’s cycles.
How are ovarian reserve factors investigated in a fertility setting?
- FSH (on day 2-5 of cycle)
- Antral follicle count
What is considered an ideal result on a d 2-5 FSH test?
Less than 10. 50+ suggests menopause.
How are uterine factors causing infertility invesitgated?
Pelvic USS
How are tubal factors causing infertility investigated?
Ideally: Laparoscopy w/ dye, shows passage through tube well but expensive and surgical risk.
Alternatives:
- Hysertosalpingo Contrast Sonography
- Hysterosalpingogram
Both use dye but one is x-ray the other is USS
What should be done in primary care to aid fertility?
- Reassure couple
- Educate (on concepts of fertility, high chance of conception, what they can do to boost their odds)
- Lifestyle advice (smoking, drinking, exercise, WEIGHT LOSS)
- Optimise management of any pre-existing conditions
- Ensure meds are safe for use in pregnancy
- Tests for STIs
What are the secondary care options for couples with fertility issues?
- Ovulation induction (give clomifene citrate)
- Treat any underlying conditions (e.g. hydrosalpinx)
What can be done in tertiary care (specialist centres) to help couples with fertility issues?
Refer to fertility clinic for…
- Inter Uterine Insertion (IUI), offered to same sex couples using surrogates or couples who can’t have penetrative sex.
- IVF, for most couples
- Intracytoplasmic sperm insertion, best option for male factor issues
What is the NICE recommendation in regards to IVF, and what actually happens?
NICE says if not pregnant after two years of RUPS, should get 3 cycles of IVF. In reality most people get one and then have to go private.
Relevant as the success rate is approx. 35%
How is infertility diagnosed?
Process of exclusion, looking for clear causes, possible causes and unexplained causes.
What history points would you look for in a woman presenting with infertility?
- AGE
- Previous fertility (primary vs secondary)
- Menstrual cycle, do they ovulate
- Any tubal or pelvic surgery
- Any history of PID
- Menorrhagia/ Dysmenorrhoea/ Pelvic pain (could all indicate potential causes)
What history points would you look for in a man presenting with infertility?
- General health
- Alcohol or smoking
- Previous surgery (especially for hernias or undescended testicles)
- Previous infections (STIs)
- Sexual dysfunction (erectile vs ejaculatory)
