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3A Womens health > Infertility > Flashcards

Infertility Flashcards

(47 cards)

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1
Q

Epidemiology of infertility

A

Failure to conceive after 1 year
Approx 15% (1:7) of couples
Up to 25% couples overall
Small increase in prevalence
Greater proportion of couples seek help
Considerable psychological distress

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2
Q

What are the top causes of infertility

A
  • Unexplained 25%
  • Ovulatory 25%
  • Tubal 20%
  • Uterine / peritoneal 10%
  • Male 30%
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3
Q

What do the population trends show about fertility?

A

Ave age first birth 28.5
First time more babies born to >35 than <25

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4
Q

Link between miscarriage and age

A

Likelihood of miscarriage increases from <35 to 35-40 and 40+
82.7% had chromosomal abnormalities, Brambati, 1990
+ Increased incidence of Downs
+ Increased maternal risks of pregnancy

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5
Q

What are the principles of care for infertility?

A

See both partners together
Explanation and written advice
Psychological effects of fertility problems
- Relationship difficulties (freq of SI)
- Support groups
- Counselling
Seen by specialist team
- improves effectiveness and efficiency of treatment & patient satisfaction with care

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6
Q

Initial advice to give when tackling infertility?

A

80% Couples (<40yrs) conceive in first year
Half of remaining will conceive in second year (CCR 90%)
Inform effect of age
Preconception advice
Refer after one year
Criteria for early referral
- Female age >35
- Known or suspected problem

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7
Q

What is the criteria for early referral for females?

A
  • Female
  • Age > 35
  • Menstrual disorder
  • Previous abdominal / pelvic surgery
  • Previous PID / STD
  • Abnormal pelvic examination
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8
Q

What is the criteria for early referral in males?

A

Previous genital pathology
Previous urogenital surgery
Previous STD
Systemic Illness
Abnormal genital examination

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9
Q

What is some good advice for preconception?

A

Intercourse – 2-3 x week
Folic acid – 0.4mg (5mg high risk)
Smear
Rubella
Smoking – cessation services
Pre-existing medical conditions
Drug history (prescribed / recreational)
Environmental / occupational exposure
Alcohol (women none)
Weight (BMI 19 – 30)

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10
Q

What are some reproductive disorders associated with obesity?

A

PCOS
MISCARRIAGE
INFERTILITY
OBSTETRIC COMPLICATIONS
Lower ART success

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11
Q

Obesity and infertility

A
  • BMI > 30 - longer to conceive
  • BMI > 30 - lower success with IVF
  • BMI and anovulation – losing weight improves chance
  • BFS advise inappropriate to treat if BMI >35
  • Men with BMI >30 reduced fertility
  • Group programmes more effective
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12
Q

Investigations for infertility

A
  • Ovulation / ovarian function / ovarian reserve
  • Semen Quality
  • Tubal Patency (+ Uterus)
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13
Q

How do we check ovulation?

A

Mid-luteal Progesterone
<16 anov
>16 < 30 equivocal
> 30 ovular
Series if long / irregular cycles

Don’t test
Temperature
LH urine testing
TFT’s, Prolactin (if ovulating)
Endometrial biopsy

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14
Q

How do we carry out ovarian reserve testing?

A
  • FSH (day2)
    >8.9 - low response
    <4 - high response
  • Antral Follicle Count (AFC)
    <4 - low response
    >16 - high response
  • Antimullerian Hormone (AMH)
    <5.4 - low response
    >25 - high response
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15
Q

How do we carry out male semen investigations?

A

Semen Analysis
WHO (2010) methodology
- Count (>15m/ml)
- Motility (>32%)
- Morphology (>4%)
- Total >7.5m
Repeat if abnormal
Anti-sperm Antibodies – not required

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16
Q

When should we refer to NHS fertility clinic?

A

Pathway agreed with Sheffield CCG
Referral after >1 year (sooner if indicated)
Initial investigations by GP
- Hormone profile (D2 FSH, D21 Prog)
- TFT, Prolactin – if indicated
- Rubella
- Smear
- Swabs
- Semen analysis
Pro-forma (couple) – Choose and Book
Seen in Dedicated fertility Clinic as couple

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17
Q

What are some further investigations for male infertility?

A

Interpret SA in light of history – illness, drugs etc
Clinical examination
- Secondary sexual characteristics
- Testicular size
Further tests (if Count <5m/ml)
- Endocrine (FSH, LH, Test, Prolactin)
- Karyotype (e.g. Klinefelters)
- Cystic Fibrosis Screen – link with CBAVD
Testicular biopsy (azoospermia)
- Only if cryopreservation facilities
Imaging – Vasogram, ultrasound, Urology

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18
Q

Tubal patency/ anatomy

A

Tubal Patency testing
Low risk
Hysterosalpingogram (HSG)
HyCoSy
High risk
When pathology suspected
STI, PID
Pain
Previous surgery
Laparoscopy + dye
USS

Swabs before instrumentation

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19
Q

What are some treatments for male infertility?

Study These Flashcards
A

Mild - Intrauterine Insemination (IUI) - ?
Moderate abnormality - IVF
Severe – Intracytoplasmic Sperm Injection (ICSI)
Azoospermia
- Surgical Sperm Recovery
- Donor Insemination
Surgery
- Correction of epidymal block
- Vasectomy reversal
- Varicocele – no benefit
Hormonal
- Hypogonadotrophic hypogonadism - Gonadotrophins
- Hyperprolacinaemia - Bromocriptine with sexual dysfunction

20
Q

What are some social issues in male that can cause infertility?

Study These Flashcards
A

Heat - occupation
Underpants / boxers ?
Smoking
Alcohol
Occupational exposure
Diet / Supplements
Folic acid (5mg) and Zinc (55mg)
? Vitamin E / selenium
Weight

21
Q

Infertility and WHO Group 1 (Low FSH/LH/E2

Study These Flashcards
A

Stress
Weight loss
Exercise
Kallman’s

Treatments
FSH+LH
GnRH pump
Normalise weight

22
Q

Endocrine causes of infertility

Study These Flashcards
A

Thyroid
Adrenal
Adenoma – Prolactin – Tx Bromocriptine
Sheehan’s – Treatment - FSH+LH

23
Q

PCOS and infertility

Study These Flashcards
A

Normal FSH, USS, androgens
85% of causes
Treatment – Ovulation Induction (Clomifene

24
Q

Menopause and infertility

Study These Flashcards
A

High FSH
Treatment - Donor Egg

25
PCOS features
Rotterdam Criteria 2003 - 2 out of 3 criteria Anovulation / oligo/amenorhoea Polycystic ovaries on scan (TVS) One ovary >12 small follicles Vol > 10cc Raised Androgens Clinical or biochemical exclude adrenal cause)
26
Treatment for PCOS
Normalise weight Clomifene (or Tamoxifen) Up to 6 cycles (NICE 2013) Monitor (Progesterone & USS) Inform of multiple preg rate (6-8%) >12 months ? Ovarian Ca risk Metformin Less effective than clomifene alone Less effective in obese May help if clomifene resistant GI side effects
27
What are some further management of certain ovulatory disorders such as PCOS?
Clomifene / metformin resistant PCOS Laparoscopic Ovarian Drilling Gonadotrophin OvuIation Induction Failure to conceive after 6 ovulatory CC cycles (New in NICE 2013) Gonadotrophins (low dose step up, no agonist) Multiple pregnancy (20%) Monitoring Ovarian Hyperstimulation Syndrome (OHSS)
28
Laparoscopic ovarian drilling
- Reproductive performance - 1/2 conceive in the first year - 1/3 continue to benefit for many years - Dec Miscarriage & recurrent miscarriage - Ovulation in 90% - Pregnancy in 70%
29
Sites and causes of Tubal disease?
Sites Proximal Distal Hydrosalpinx Adhesions Ovarian Tubal Causes Infections - Chlamydia - Gonorrhoea Endometriosis Surgical - Adhesions - Sterilisation
30
What are the treatment options for tubal disease?
Tubal Surgery (Laparotomy or Laparoscopy) - Adhesiolysis - 40% - Salpingostomy - 30% - Proximal anastamosis - 30% - Reversal of sterilisation - 60-80% Tubal catheterisation - Selective Salpingography - 21% - Hysteroscopic - 49% In vitro Fertilisation (IVF) – 30-40%
31
What is the medical treatment of endometriosis?
Medical treatment of minimal or mild endometriosis does not improve chances of pregnancy
32
What are the surgeries used for mild endometriosis?
Laparoscopic treatment ablation or resection of minimal and mild disease increases pregnancy and live birth rates (OR 1.64; 95% CI 1.05 to 2.57). Cochrane Database of Systematic Reviews 2003;1, 2003.. Laparoscopic cystectomy for endometrioma increased pregnancy rates compared with drainage and coagulation
33
What are the features of unexplained infertility?
- Diagnosis of exclusion – 25% - Spontaneous cumulative pregnancy rate between 33% and 60% at 3 years Consider age and other factors - Treatment largely empirical Consider side effects and risks
34
Treatment of Unexplained Infertility
Clomiphene Not recommended in NICE 2013 SIUI Not recommended in NICE 2013 IVF Recommended after 2 years infertility
35
What are the types of assisted conception?
Ovulation Induction (OI) Stimulated Intrauterine Insemination (SIUI) In Vitro Fertilisation (IVF) - Intracytoplasmic Sperm Injection (ICSI) - Surgical Sperm Recovery (PESA/TESE) - Embryo Freezing Donor Insemination Donor Egg Donor Embryo Host Surrogacy Everything below IVF is HFEA licensed
36
What are some embryo transfer strategies
Current HFEA limit = 10% Women < 37 - 1st cycle - 1 ET - 2nd cycle – 1 ET if top quality embryos, 2ET if no top quality 3rd cycle 2ET Women 37-39 - 1st and 2nd cycles - 1 ET if top quality embryos, 2ET if no top quality - 3rd cycle 2ET Women 40-42 – 2ET
37
What are the risks of IVF?
Multiple Pregnancy Miscarriage Ectopic Fetal abnormality? Ovarian Hyperstimulation Syndrome (OHSS) 1-5% (lower @JW) Egg Collection (1:2000) Longer term - ? Ovarian Ca
38
What are the patient factors that affect success?
- Age - Cause of Infertility - Previous Pregnancies - Duration of Infertility - Number of Previous attempts - Specific medical conditions - Environmental factors
39
What are the maternal risks as age increases?
- Increased risks of - Hypertension - Diabetes - IUGR - Operative delivery - Thromboembolism - Maternal death
40
What are some uterine abnormalities?
Associations with infertility / miscarriage Exact role is not clear Abnormalities - Adhesions - Polyps - Fibroids - Septate Uterus
41
Site of fibroids & IVF impact
Intramural fibroids reduced chance of pregnancy with ART OR 0.46, 95% CI 0.24 to 0.88) Submucous myoma lower pregnancy rates RR 0.30, 95% CI 0.13 to 0.70
42
Features of myomectomy
Pregnancy rate following myomectomy higher when compared with women with untreated myomas 42% vs 25% No RCTs – further research needed
43
Examples of intrauterine adhesions
Rare - may result from previous uterine evacuation or surgery Associated with oligo-amenorrhoea Hysteroscopic adhesiolysis - restored normal menstrual pattern in 81% - 63% conceived - 37% delivered a viable infant
44
What are some Mullerian abnormalities
Normal uterus Dysmorphic uterus Septate uterus Bicorporeal uterus Hemi uterus Aplastic uterus
45
What is a septate uterus?
Incidence not increased in infertilty - 2-3% women Associated with RPL and Preterm birth Hysteroscopic metroplasty not shown to increase pregnancy rates Further work required
46
Access to IVF according to NICE 2013
Treat after 2 years or 12 months insemination Discuss risks and benefits Full cycle of treatment includes freezing Women < 40 years 3 full cycles Stop once age = 40 Women 40-42 1 full cycle (if no previous IVF, no low ovarian reserve) Cancelled cycles don’t count (unless low ovarian reserve) Private cycles count against total
47

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