Flashcards in Infertility Deck (31):
When are a couple considered subfertile?
If conception has not occurred after a year of regular unprotected intercourse
What percentage of couples will conceive in 1 year when having regular sex?(age under 40)
What percentage of couples will conceive within 2 years when having regular sex?
What 4 things must be met for pregnancy to occur?
1. An egg must be ovulated
2. Adequate sperm must be released
3. The sperm must reach the egg
4. The fertilized egg must implant
What are the contributors to subfertility?
*Ovulatory problems (30%)
*Male factors (25%)
*Tubal problems (25%)
*Coital problems (5%)
*Cervical problems (<5%)
NB because more than one cause may be present, the percentage total is more than 100%
What is group 1 ovulation disorder?
*Due to hypothalamic pituitary failure
*by increasing their body weight they can increase their chance of ovulation, conception and uncomplicated pregnancy
What is group 2 ovulation disorder?
*Due to hypothalamic-pituitary dysfunction predominately due to polycystic ovary syndrome
What is group 3 ovulation disorder?
*Due to ovarian failure or hypergonadotrophic hypogonadism
What does polycystic ovaries describe? When dos it become PCOS?
*Characteristic trans-vaginal US appearance of multiple (12=/>) small follicles in an enlarged ovary
*PCOS: when at least two of the following 3 criteria met: i)PCO on USS
ii)irregular periods >35days apart
iii)hirsutism and/or raised serum testosterone
What is the pathology of polycystic ovaries?
*affected women demonstrate disordered LH production and peripheral insulin resistance with compensatory raised insulin levels
*combination of raised LH and insulin acting on PCO lead to increased ovarian androgen production
*raised insulin =increased adrenal androgen production
*increased intra-ovarian androgens disrupt folliculogenesis, leading to small ovarian follicles and irregular/absent ovulation
*increasing body weight leads to increased insulin and consequently androgen levels
How does weight affect PCOS?
Increasing body weight leads to increased insulin and consequently androgen levels
*Weight can modify the phenotype of PCOS
How does PCO present?
*without the syndrome generally cause no symptoms
Why is miscarriage more common in PCOS?
*may be related to the increased levels of LH and/or insulin and increased body weight
What blood tests are used to investigate anovulation? Raised, low or normal, what does it mean?
>Raised in ovarian failure
>Low in hypothalmic disorders
>normal in PCOS
>High in PCOS
>Low in ovarian failure
(To exclude prolactinoma)
>Often raised in PCOS but not diagnostic
>Raised in PCOS
*TV USS to look for PCO
What is intrauterine insemination?
A fertility treatment: introduction of prepared sperm into the uterine cavity around the time of ovulation
When can intrauterine insemination be considered as a treatment option?
*People who are unable to or whould find it difficult to have vaginal intercourse (disability or psychosexual problem)
*People with conditions that require special consideration in relation to methods of conception (HIV)
*Same sex relationships
What percentage of women aged under 40 will conceive within 6 cycles of intrauterine insemination?
When people come to the doctors with concerns about delays in conception, what initial assessment should be done?
What lifestyle advice should be given to those trying to conceive?
>Women: no more than 1-2 units of alcohol once or twice a per week (avoid intoxication)
>Men: excessive alcohol intake detrimental to semen quality
>Women and Men BMI>/=30 reduces fertility
>Aim for 20-25 BMI
>Women BMI <19 should increase body weight
*Folic acid supplementation 0.4mg per day
>5mg per day if they have diabeties, previous baby with neural tube defect, on anti-epileptic medication
>Women reduces fertility
>Men reduces semen quality
What investigations can be done to determine female fertility problems?
*Mid-luteal progesterone to assess ovulation (Blood test taken 7 days prior to anticipated period)
*FSH and LH measured if menstrual irregularity
*Ovarian reserve testing
What investigations can be done if suspected tubal and uterine abnormalities cause of infertility?
*hysterosalphingography in women without comorbidities (PID/ectopic/endometriosis)
*Laparoscopy and dye for women with comorbidities
What is ovarian reserve testing? Used for?
Use one of the measures to predict the likely ovarian response to gonadotrophin stimulation in IVF
1. Total antral follicle count
2. anti-Mullerian hormone level
3. FSH hormone level
What is looked at in semen analysis?
*total sperm number
What Investigations can be done for male fertility?
*Ultrasound -if urinary symptoms present/abnormal finding on examination
*Viral screening (if having IVF)
Management of women with group 1 ovulation disorder?
*Advise to gain weight to increase ovulation
*Should be offered gonadotrophin-releasing hormone or gonadotrophins with LH to induce ovulation
Management of women with group II ovulation disorder?
This is mostly due to PCOS
*Clomifene Citrate (anti-oestrogen)
*Metformin in combination with clomifene citrate can be considered
*BMI >30 should be advised to lose weight
*Women with CC treatment should only have for 6 months and have USS
What is the management for group III ovulation disorder?
*if due to hyperprolactinaemia should be offered dopamine agonists
What is included in assisted conception?
*Gamete intrafollopian transfer
*in vitro fertilisation and embryo transfer
*intractoplasmic sperm injections
What is the access criteria for offering IVF?
*3 cycles if < 40 years old
*1 cycle if >40 years old
What is the success rate of IVF?
*Success rate decreased with age