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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%)
*Unexplained (30%)
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?

*mainly genetic
*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

*Androgen levels
>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?

Initial assessment
>Lifestyle enquiry
>Sexual history


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

*Body weight
>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
*Rubella testing
*Tubal investigations
*Ovarian reserve testing


What investigations can be done if suspected tubal and uterine abnormalities cause of infertility?

*Chlamydia testing
*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?

*sperm concentration
*total sperm number
*total motility


What Investigations can be done for male fertility?

*Sperm analysis
*Hormone analysis
*Ultrasound -if urinary symptoms present/abnormal finding on examination
*Testicular biopsy
*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?

*intrauterine insemination
*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


What prescribed medicine can cause problems with fertility?

*antipsycotics and metroclopramide increase prolactin levels
*NSAIDs associated with luteinised unruptured follicles