Infertility Flashcards
(24 cards)
Infertility definition
NICE definition - The period of time people have been trying to conceive without success, after which formal investigation is justified and possible treatment implemented (NICE, 2017)
Leading causes in uk
unexplained infertility (no identified male or female cause; 25%)
ovulatory disorders (25%)
tubal damage (20%)
factors in the male causing infertility (30%)
uterine or peritoneal disorders (10%)
1st step initial advice to people concerned in delays about conception - lifestyle advice
Regular vaginal intercourse every 2-3 days *1-2 units of alcohol per week for women*3-4 units of alcohol per week for men- excessive affect sperm quality (Grover et al,2014)*Smoking cessation can be offered *BMI 19-29*Occupational Hazards*Prescribed, over the counter and recreational drugs
Other pre conceptual advice*Folic Acid*Rubella susceptibility and cervical smear
Risk factors for infertility
Fertility naturally declines with a woman’s age - ovarian reserve and oocyte qualityrapidly decreasing from age 37
Paternal age also a risk factor - increasing age (over 55) can affect sperm motility
-STI’s
2nd step - investigations
If not conceived after 1yr of unprotected reg sex
Offer climatically advice and assessment
semen analysis/ assessment of ovulation
Early specialist refer all id >36 yrs old and there is known clinical cause
Counselling
Investigations into female federalists
Is the woman ovulating?
-Patient to be asked about frequency and regularity of menstrual cycle -Offer blood test to measure serum progesterone level in mid-luteal phase (day 21 of 28 day cycle) in regular cycles-Irregular cycles offer blood test for serum gonadotropins (FSH and LH)
Is there any pathology of the uterus or fallopian tubes?
-Pelvic Ultrasound scan -Hycosy or Hysterosalpingography (HSG)-Hysteroscopy -Laparoscopy
What is the woman’s ovarian reserve?
AMH- Anti Mullerian hormoneAFC- Antral Follicle count
PCOS - diagnosis
Rotterdam Criteria (ESHRE/ASRM, 2004):*Polycystic ovaries on ultrasound *Ovulatory dysfunction- Oligomenorrhoea or anovulation*Clinical and/or biochemical signs of hyperandrogenism
What are implications of pcos
Increased risk of cardiovascular disease-Metabolic disorders (type II diabetes)-Obstructive sleep apnoea-Cancer -pregnancy implications → increased rates of gestational diabetes, pregnancy-induced hypertension, pre-eclampsia, caesarean delivery, miscarriage, macrosomia, newborn admission to the neonatal intensive care unit. Offer women with known PCOS GTT before 20 weeks gestation
What is the Treatment for PCOS in patients wishing to conceive?
Advise to lose weight if BMI is >30
*Commence on Clomifene Citrate - USS tracking with first cycle and ovulation kits
*And/Or Metformin (informed of side effects)
*6 cycles maximum
And if the woman doesn’t respond
etrozole can be considered
*Ovarian Drilling
*Stimulation with Gonadotropins
Fallopian tubes
Fallopian tube obstruction occurs in 12% to 33% of infertile couples
Tubal damage can be treated with Transcervical tubal cannulation or catheterisation procedure → improves chance of pregnancy in women with proximal tubal obstruction.
Patients with hydrosalpinges (fluid blockage in fallopian tube) →Salpingectomy before IVF as improves chance of live birth
Uterine disorders
Women with amenorrhea who are found to have uterine adhesions → offered hysteroscopic adhesiolysis
Endometriosis → When the tissue/cells similar to the lining of the womb (endometrium) grows outside of the uterus e.g- on the fallopian tubes or ovaries
Treatment→ Offer excision or ablation of endometriosis plus adhesiolysis for endometriosis as well as laparoscopic ovarian cystectomy with excision of the cyst wall to women with endometriomas.Need to consider risks of procedure and ovarian reserve of woman
Investigations into male fertility - normal parameters
Volume 1.5ml or more
Count (Concentration)15 million spermatozoa per ml
Total Motility (percentage of progressive motility and non-progressive motility): 40% or more motile or 32% or more with progressive motility
Morphology (≥4%)
Causes of treatment of male infertility
Hormonal → medical management
Obstruction → offered surgical correction
Ejaculatory failure
Intrauterine insemination - who is offered his treatment
Unable to have vaginal intercourse -Same sex relationship & single women (donor sperm)-Conditions that require specific contraception methods (e.g- HIV male)
NICE (2017)- not conceived after 6 cycles with IUI can offer another 6 before IVF considered
IUI - what happens
Natural or stimulated (medicated)-IUI timed with ovulation and sperm is ‘washed’
Oocyte ans sperm donation - who is offered this treatment
offered this treatment?
-Premature ovarian failure (AMH<2.0)-Turners Syndrome-Bilateral oophorectomy-Post chemo-Recurrent IVF failure
-Same Sex Couples-Single Women-Male factor of sperm quality
Assisted conception - who is offered
-Unexplained infertility-Tubal damage-Male factor -Ovulation disorders -People using surrogacy-Medical history
What does ivfcycle involved
Medical assessment - BP/BMI/history/VTE/travel
Viral screening & Consent forms
Ovarian stimulation
Monitoring Scans
Oocyte maturation → Trigger HCG
Egg collection & Sperm sample
Luteal support
Embryo transfer & Embryo Freezing
Pregnancy Test
Preimplantation genetic testing for aneuploidy
Method of screening the embryo to assess its chromosomal normalcy
We remove 5-7 cells from the embryos that are suitable for freezing on day 5
These cells are sent for analysis and the embryos frozen until the results are returned which can take 2-3 weeks
Pita- a risks and benefits
Cost £500 per embryo biopsied (up to 6), £375 thereafter
Not 100% pregnancy rate if embryo is normal
May not have any normal embryos and therefore no transfer
Embryos may be damaged during biopsy
The benefit of PGT-A is a reduction in the time to pregnancyRated Green for reducing the chances of miscarriage for most fertility patients
Naha and private provisions for female couples
Female same sex couples, some ICB’s will only refer for IVF once couple have had 6-12 rounds of artificial insemination (self funded) but this should be changing. Many ICB’s are reviewing IVF policy in line with upcoming NICE guidlines 2025
NHS male couple care
Male same sex couples are not funded for treatment on the NHS as IVF would require a surrogate mother and surrogacy is not funded in England due to legal reasons
MDT
Consultant in Reproductive Medicine & GynaecologyEmbryologists Lab Technicians Fertility Midwives & NursesHealthcare Assistants Counsellors (Genetic)
Midwife (Specialist teams) Obstetric ConsultantReproductive MedicineAnaesthetists Healthcare AssistantsLactation Specialists/ BF support workersHealth Visitor
Role of midwife t booking appt
-Clinical History & Assessment
-Is the patient taking any medications?
-Is an IVF pregnancy a risk factor?
-Obstetric Consultant referral required?
-Is the patient a surrogate?
-Assess mental health
