Infertility Flashcards
(38 cards)
1
Q
Incidence of infertility
A
1 in 7 couples report infertility problems
2
Q
Infertility definitions
A
The inability of a couple to conceive after 12 months of regular intercourse without use of contraception.
3
Q
Chance of conception
A
- Over 80% of couples in the general population will conceive within 1 year if:
- the woman is aged under 40 years and
- they do not use contraception and have regular sexual intercourse.
- Of those who do not conceive in the first year, about half will do so in the second year (cumulative pregnancy rate over 90%).
4
Q
Female history
A
- Duration of infertility
- Previous contraception
- Fertility in previous relationships
- Previous pregnancies and complications
- Menstrual history
- Medical and surgical history
- Sexual history
- Previous investigations
- Psychological assessment
5
Q
Female examination
A
- Weight
- Height
- BMI (kg/m2)
- Fat and hair distribution
- Galactorrhoea
- Abdominal examination
- Pelvic examination
6
Q
Clinical measurement of androgen excess
A
Ferriman Gallwey Score
7
Q
Biochemical measurement of androgen excess
A
- Testosterone (T)
- Dehydroepiandrosterone sulphate (DHEAS)
- if DHEAS is greater than 700 mcg/dL (18.9 micromol/L) adrenal computed tomography (CT) is recommended to look for an androgen-secreting adrenal tumor
- 17-OH Progesterone
8
Q
What is looked for on a pelvic examination?
A
- Masses
- Pelvic distortion
- Tenderness
- Vaginal septum
- Cervical abnormalities
9
Q
Fibroid symptoms
A
- Pressure symptoms
- Period problems
- Infertility
10
Q
Baseline female investigations
A
- Rubella immunity
- Chlamydia
- TSH
- if periods are regular: Mid luteal progesterone ( 7 days prior to expected period)
- if periods are irregular: Mid luteal progesterone ( 7 days prior to expected period). And repeat weekly until start if next menstrual cycle. Also measure serum gonadotrophins (FSH and LH).
11
Q
Baseline male investigations
A
semen analysis
12
Q
Investigations at Fertility Clinic
A
- Pelvic Ultrasound
- Physical examination
- Testing for ovulation
- Tubal patency test
- Semen analysis repeat if required
13
Q
Assessment of ovulation in women who are concerned about their fertility.
A
- These women should be asked about the frequency and regularity of their menstrual cycles.
- Women with regular monthly menstrual cycles should be informed that they are likely to be ovulating.
14
Q
Assessment of ovulation in women who are undergoing investigations for infertility (even if they have regular menstrual cycles)
A
Mid luteal progesterone ( 7 days prior to expected period) to confirm ovulation.
15
Q
Assessment of ovulation in women with prolonged irregular menstrual cycles.
A
- Mid luteal progesterone ( 7 days prior to expected period). And repeat weekly until start if next menstrual cycle.
- Also measure serum gonadotrophins (FSH and LH ).
16
Q
Investigation of suspected tubal and uterine abnormalities
A
hysterosalpingography (HSG)
17
Q
Male history
A
- Developmental
- Testicular descent
- Change in shaving frequency
- Loss of body hair
- Infections
- Mumps
- Sexually transmitted diseases
- Surgical
- Varicocele repair
- Vasectomy
- Previous fertility
- Drugs/environmental
- Anabolic steroids
- Chemotherapy
- Radiation
- Recreational drugs
- Sexual history
- Libido - sexual derive
- Frequency of intercourse
- Previous fertility assessment
18
Q
Male examination
A
- Weight
- Height
- BMI (kg/m2)
- Fat and hair distribution (hypoandrogenism)
- Abdominal and inguinal examination
- Genital examination
- Epididymis
- Testes
- Vas deferens
- Varicocele
19
Q
Varicocele
A
- is a dilatation of the pampiniform plexus of the spermatic veins in the scrotum
- surgery for varicoceles does not improve pregnancy rates (should not be offered as a form of fertility treatment)
20
Q
Klinefelter syndrome
A
One of the most common causes of primary hypogonadism with impaired spermatogenesis and testosterone deficiency.
21
Q
Classification of ovulatory disorders
A
- Group I: hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism).
- Group II: hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome).
- Group III: premature ovarian insufficiency (POI).
22
Q
WHO Group I ovulation disorders
A
- Increasing their body weight if they have a BMI of less than 19
- Moderating their exercise levels if they undertake high levels of exercise
- Offer pulsatile administration of gonadotrophin-releasing hormone or gonadotrophins with luteinising hormone activity to induce ovulation
23
Q
Which criteria is used to diagnose polycystic ovary syndrome?
A
The Rotterdam criteria
24
Q
Rotterdam criteria
A
Two out of the three criteria must be met:
- Polycystic ovaries on ultrasound or direct inspection
- 12 or more small follicles measuring around 2-9mm or volume of ovaries >10cm2
- Oligo or anovulation
- usually seen in women with menstrual cycles greater than 35 days apart or with short cycles (less than 21). Even women with regular cycles may be anovulatory
- Hyperandrogenism
- clinical - hirstuism, acne
- biochemical - testosterone
25
Symptoms of Polycystic ovary syndrome
**HAIR**
* **H**irsutism
* **A**menorrhoa
* **I**rregular periods / **I**ncreased weight
* **R**educed fertility and miscarriage
26
Investigations for polycystic ovary syndrome
* General blood tests
* FBC, U&E, TFTs
* Specific blood tests
* Androgen levels, SHBG (sex hormone binding globulin), LH, FSH, prolactin
* Radiology
* Transvaginal ultrasound scan
27
Treatment for polycystic ovary syndrome
* Conservative
* Weight loss
* Medical
* Hirsutism - oral contrceptive pills with an anti-androgen effect (eg Yasmin)
* Subfertility - metformin may help
* Inducing ovulation (eg clomifene)
28
Complications of polycystic ovary syndrome
* Infertility
* Type 2 diabetes mellitus
* Gestational diabetes
* Depression
* Increased weight
29
Ovulation induction
* Clomiphene
* Gonadotrophins
* GnRH
30
Clomifene: clinical use
* Selective oestrogen receptor modulator
* Dose choice 50mg - 100mg for 5 days
* Monitoring
* Follicle scanning in 1st cycle
* 15% require dose adjustment
* Side effects
* Vasomotor
* Visual
31
Hydrosalpinges treatment
Women with hydrosalpinges should be offered salpingectomy, preferably by laparoscopy, before IVF treatment because this improves the chance of a live birth.
32
Reversal of sterilisation
* No longer available on NHS
* Consider IVF
33
Male factor infertility
* Urologist appointment if appropriate
* IVF/ICSI
* Intra-uterine insemination
* Surgery
* Reversal of vasectomy
* Surgical sperm retrieval
* Donor insemination
34
Investigations for Azoospermia
* History
* Examination
* FSH, LH, Testosterone, Karyotype, PRL
* CF screen
35
Azoospermia treatment
* Surgical sperm retrieval
* Microepididymal sperm aspiration
* Testicular sperm extraction
36
Unexplained infertility
* Do not offer oral ovarian stimulation agents (such as clomifene) to women with unexplained infertility
* Advise women with unexplained infertility who are having regular unprotected sexual intercourse to try to conceive for a total of 2 years (this can include up to 1 year before their fertility investigations) before IVF will be considered
* Offer IVF treatment
37
Access criteria for NHS IVF treatment in Scotland
* both partners have no living children
* both partners are non-smokers
* BMI of female partner must be above 18.5 and below 30
* neither partner has undergone voluntary sterilisation, even if sterilisation reversal has been self-funded
38
Intracytoplasmic Sperm Injection (ICSI)
* Injection of mature eggs with single sperm
* Incubation overnight
* Embryo transfer
