Why is infertility increasing?
older women rise in increase in chlamydia infections increase in obesity increasing male factor infertility increasing awareness of treatments
What is the definition of infertility?
- failure to get pregnant
- after 12 months or more
- regular unprotected sexual intercourse
- couple have never had a child
Describe the difference between Primary and Secondary Infertility
Primary = couple have never conceived
Secondary = couple have previously conceived, BUT pregnancy may not have been successful
=> e.g. miscarriage or ectopic pregnancy
What factors can increase the likelihood of getting pregnant?
- Woman aged < 30
- Previous pregnancy
- < 3 years trying to conceive
- Intercourse around time of ovulation
- BMI 18.5 – 30
- Both partners non-smokers
- Caffeine intake < 2 cups of coffee daily
- No use of recreational drugs
At what maternal age does the steep decline of fertility start?
Around the age of 35
Males account for 1/3 of infertility, whilst females account for the other 2/3 of infertility. TRUE/FALSE?
In what physiological situations would cause anovulatory infertility (no egg release)
- before puberty
- lactation (breastfeeding)
What gynaecological conditions can cause anovulatory infertility?
=> anorexia/bulimia, excessive exercise
=> hyperprolactinaemia, tumours, Sheehan syndrome
=> PCOS, premature ovarian failure
What systematic disorder is known to cause anovulatory infertility?
chronic renal failure
What drugs can cause anovulation and therefore infertility?
Oral Contraceptive Pill
Can anorexia cause anovulation?
Causes low FSH, LH and Oestradiol
What are the clinical features of anorexia?
low BMI (below 18.5)
loss of hair
low pulse and BP
How does Polycystic Ovary syndrome usually present?
- hirsutism or acne
- cycle abnormalities and infertility
What endocrine abnormalities are present in Polycystic Ovary Syndrome?
high free androgens
impaired glucose tolerance
What is the diagnostic criteria for Polycystic Ovary Syndrome?
2 out of 3 of:
- chronic anovulation
- polycystic ovaries
What are the possible causes of premature ovarian failure?
- genetic (Turner’s syndrome, fragile X)
- oophorectomy (ovary removal)
How does premature ovarian failure present clinically?
Describe the hormonal effects of premature ovarian failure?
What are the possible infective causes of tubal disease?
- Pelvic inflammatory disease
=> chlamydia, gonorrhoea = most common
=> appendicitis, intra-abdominal abscess
- Following a procedure:
=> IUCD insertion, hysteroscopy, HSG
What are the most common causes of tubal disease that are not from an infection?
- surgical (sterilisation, ectopic pregnancies)
What is a Hydrosalpinx?
Distended fallopian tube
What condition is characterised by the presence of endometrial glands outside uterine cavity?
What symptoms are experienced in endometriosis?
- dysmenorrhoea (cramps)
- dysparenuia (pain during sex)
- menorrhagia (heavy bleeding)
- painful defaecation
- chronic pelvic pain
What coital disorders can contribute to male factor infertility?
What genetic conditions can cause male factor infertility?
Kleinfelter Syndrome (XXY) Y chromosome deletion Immotile Cilia (e.g. CF)
Testicular torsions and varicoceles can cause what subtype of male factor infertility?
What drugs can cause a decrease in male sperm count?
- Alcohol, Tobacco, Marijuana, Cocaine
- Testosterone Supplements
- Specific chemo drugs
- Long term use of certain antibiotics
What drugs can cause hormone imbalance?
Marijuana Testosterone supplements Anabolic Steroids Opiates Spironolactone Drugs for schizophrenia/ tri-cyclic antidepressants
What drugs can cause decreased sex drive?
Excessive alcohol SSRIs Opiates Spironolactone Beta Blockers Lithium
What drugs can cause erectile dysfunction?
Excessive alcohol, Tobacco, Cocaine Spironolactone and other diuretics Beta-blockers Alpha-Blockers Schizophrenia/ Tri-cyclic antidepressants Lithium
Decrease ability of sperm to fertilise egg?
- Ca channel blockers
- Tetracyclic antibiotics
- Drugs for gout
Describe the hormone profile in non-obstructive male infertility
High LH and FSH
What examinations are carried out on a female attending an infertility clinic?
- Assessing body hair distribution
- Pelvic examination => assessing for uterine and ovarian abnormalities/tenderness/mobility
What examinations are carried out on a male attending the infertility clinic?
- Genital examination
=> Assessing size/position testes
=> Penile abnormalities
=> presence vas deferens
=> presence varicoceles
What investigations should females experience at an infertility clinic?
- endocervical swab for chlamydia
- cervical smear if due
- blood for rubella immunity
- midluteal progesterone level progesterone
- Test of tubal patency
What investigation is used to test tubal patency?
When is laparoscopy used to test tubal patency?
Known previous pathology:
- ectopic pregnancy
- ruptured appendix
Hx suggestive of pathology:
When is hysteroscopy carried out?
Cases where suspected or known endometrial pathology:
i.e. uterine septum, adhesions, polyp
What hormones should be tested for in an anovulatory cycle or infrequent periods?
- Urine HCG
- Testosterone and SHBG
- LH, FSH and oestradiol
How far apart should 2 semen analysis’ be carried out?
twice over 6 weeks apart
What imaging modality can be used to visualise testicular cancer?
Describe how GnRH is released from the hypothalamus
Describe the difference in frequency of FSH and LH pulses
FSH = low frequency pulses LH = high frequency pulses
How does FSH affect male and females differently?
- Stimulates follicular development
- Thickens endometrium
- Stimulates sertoli cells
Describe the difference in the effects of LH in a male and female
- Peak stimulates ovulation
- Stimulates corpus luteum development
- Thickens endometrium
- Stimulates Leydig cells
- Testosterone secretion
What phase of the menstrual cycle can be variable?
What do ovulation test kits measure?
this usually occurs 36h before ovulation
Where is oestrogen secreted from?
ovaries - follicle
(placenta in pregnancy)
What structures secrete progesterone?
corpus luteum to maintain early pregnancy
placenta during pregnancy
What effect does progesterone have on body temperature?
thermogenic effect => increases basal body temperature
How is oligomenorrrhoea described?
cycles >35 days
Describe the difference between Primary and Secondary Amenorrhoea
Primary - never had periods
Secondary - had periods that have now stopped
How is a male with “no sperm” described?
What aspects of sperm are studied when assessing spermatogenesis?
How do the WHO classify causes of female infertility?
GROUP I - Hypothalamic pituitary failure
GROUP II - Hypothalamic pituitary dysfunction
GROUP III - Ovarian failure
What are the main causes of hypothalamic/pituitary failure?
- Excessive exercise
- Anorexia / low BMI
- Head trauma
- Kallman’s syndrome
- Drugs (steroids, opiates)
What BMI should females aim for when attempting to conceive ?
18.5 > 30
What hormone therapies can be used to treat Group 1 of anovulatory disorders (Hypothalamic Pituitary failure)?
- Pulsatile GnRH
- Gonadotrophin (FSH+LH) injections
What are the advantages of Pulsatile GnRH Treatment?
90% women ovulate
82% pregnant in a year
Multiple preg rate not significantly increased
What is the adverse effect of using FSH and LH injections?
higher multiple pregnancy rates
What hormones are found to be abnormal in Group 2 - Hypothalamic pituitary dysfunction?
LH in excess
GnRH and Oestrogen normal
What is the most common disorder which falls under Group 2 Hypothalamic Pituitary dysfunction
Polycystic Ovary Syndrome
Do most with Polycystic Ovary Syndrome present with Oligomenorrhoea or Amenorrhoea?
Describe the Rotterdam criteria used for diagnosis of Polycystic Ovary Syndrome?
- > 12 2-9mm follicles
- Increased ovarian volume
- Unilateral / bilateral
What is the pre-pregnancy treatment used in Polycystic Ovary Syndrome?
- Weight loss
- Life style modification: smoking, alcohol
- Folic acid 400 mcg / 5mg daily
- Check prescribed drugs
- Rubella immune
- Normal semen analysis
- Check fallopian tube is patent
What drugs can be used for ovulation induction in PCOS?
- Clomifene Citrate (Clomid)
alternatively Tamoxifen, Letrozole
What days of the cycle is Clomifene given to induce ovulation?
Describe the mechanism of Clomifene and Tamoxifen
Prevents Oestrogen negative feedback
=> Stimulates GnRH and FSH/LH release
What injection can be given to stimulate ovulation in PCOS?
What are the advantages and disadvantages of Gonadotrophic Injections?
> Higher rates of ovulation and pregnancy than oral therapies
Risk of multiple pregnancy
What therapy involves cautery to destroy parts of the ovary in the hope of inducing ovulation?
laparscopic ovarian diathermy
used in PCOS
What percentage of PCOS patients become insulin resistant?
What improvements can Metformin make in insulin resistant PCOS patients?
- Improves insulin resistance
- reduces androgen production
- Restoration of menstruation and ovulation
- May increase in pregnancy rate
- May improve sensitivity to clomifene
What are the main risks of ovulation induction?
- Ovarian hyperstimulation
- Multiple pregnancy
- Risk of ovarian cancer
What groups are at increased risk of ovarian hyperstimulation in induced ovulation?
If <35 years old
If a mother experiences a multiple pregnancy (twins etc) what symptoms she at increased risk of?
If a mother experiences a multiple pregnancy (twins etc) what specific pregnancy complications she at increased risk of?
- Low birth weight
- Stillbirth / neonatal death
- Twin-twin transfusion syndrome
What disabilities are most likely to be associated with twin births?
congenital heart disease
Describe the hormone profile of a patient with ovarian failure?
- High gonadotrophins
- Raised FSH
- Low oestrogen
What physiological situation is considered ovarian failure?/
female runs out of eggs
What can cause premature ovarian failure?
- Genetic => Turner’s/Fragile X
- Autoimmune ovarian failure
- Bilateral oophrectomy
- Pelvic radio/chemotherapy
What treatments are offered in premature ovarian failure?
- Egg/Embryo donation
- cryopreservation prior to chemo/radiotherapy
What are the main causes of testicular failure?
- Klinefelters (47XXY)
- Y chromosome microdeletion
- undescended testes
- trauma / torsion / mumps
- Pelvic radio/chemotherapy
- Autoimmune disease
What level of Prolactin indicates hyperprolactinaemia?
> 1000 iu/l on 2 or more occasions
What class of drug is used to treat hyperprolactinaemia?
If the sperm is injected int the egg for fertilisation, what is this process called?
Intracytoplasmic sperm injection (ICSI)
What procedure involves the introduction of sperm to the uterus artificially?
If a baby was to present with rubella (due to mother not being vaccinated) what symptoms can be seen?
Patent Ductus Arteriosus
What warning should be given when administering the rubella vaccine to females of child-bearing age?
Dont get pregnant within few months of getting the vaccine due to it being a LIVE formula
What treatments can be given for chlamydia infection?
Doxycycline (if macrolide allergy)
What clinical signs can indicate a potential diagnosis of PCOS?
Male sperm count is declining. TRUE/FALSE?