Infertility Flashcards
When should investigations for subfertility be offered?
After a year of actively trying
Earlier if female >/=35, amenorrhoea, oligomenorrhoea, past PID/undescended testes/cancer treatments which might affect fertility
What are the causes of subfertility?
MOTU Male factors Ovulation problems/ovarian reserve (low) - PCOS, premature ovarian failure, Turner’s syndrome, surgery, chemotherapy, excessive weight loss/exercise, hypopituitarism, hyperprolactinaemia Tubal factor - blocked tubes, PID Uterine factors/unexplained - uterine factors include endometriosis, fibroids, polyps, anatomical abnormalities
What information should be included in a subfertility history?
Age and duration of subfertility
Previous pregnancies?
Have either partner had children previously?
Menstrual history, pelvic pain, STIs, previous surgeries
Frequency of sexual intercourse
Problems during sex e.g. erectile dysfunction, dyspareunia
Male - undescended testes, mumps
Smoking, drug and alcohol abuse
What should be done when examining someone with suspected subfertility?
BMI (obesity has an adverse effect on fertility, those wit BMI over 30 are not eligible for many of the treatments)
Signs of endocrine disorder e.g. PCOS
Exclude pelvic pathology e.g. endometriosis, fibroids
Cervical smear
High vaginal and chalmydia swabs
What are the investigations in primary care for subfertility?
Chlamydia screening
Baseline hormone profile (FSH day 2-5 and LH)
TSH, prolactin, testosterone
Rubella status (vaccinate if not immune)
Mid-luteal progesterone to confirm ovulation (day 21 of 28 day cycle) - >30 indicates ovulation
Semen analysis (repeat in 3 months if abnormal after making lifestyle changes and starting multivitamins containing selenium, zinc and vitamin c)
What are the investigations for subfertility in secondary care?
TVS to rule out adnexal masses, submucosal fibroids, endometrial polyps/confirm PCOS
HSG - x-ray and contras injected through a small cannula into the cervix to demonstrate uterine anatomy and tubal patency
HyCoSy - similar to above, but using TVS instead of X-ray
Laparoscopy and dye test (gold standard for assessing tubal patency)
What lifestyle modifications are used to treat subfertility?
Weight loss, healthy diet and exercise Stop smoking +/- recreational drugs Reduce alcohol Folic acid (woman) Regular intercourse (every 2-3 days) Avoid ovulation monitors (increases stress)
How can ovulation be induced in anovulatory subfertility?
Weight loss/gain Clomifene citrate Laparoscopic ovarian drilling Gonadotrophins Metformin (unlicensed, controversial)
How does clomifene citrate work?
50mg given on days 2-6 of the cycle
It is an anti-oestrogen which increases endogenous FSH via negative feedback to the pituitary
What are the side effects o clomifene citrate?
Ho flushes
Labile mood
If severe - headaches/visual disturbance (stop immediately)
How long can clomifene be used for and why?
Only for 6-12 cycles
Due to possible link with ovarian cancer
What monitoring does the patient need when on clomifene and why?
Monitoring of the follicles by USS
Due to the risk of hyperstimulation
Who can prescribe clomifene citrate and what’s the criteria that should be met when prescribing it?
Prescribed by a specialist
Tubal patency confirmed
Semen count normal/near-normal
BMI < 30
What is laparoscopic drilling and who is it used for?
Used in PCOS patients only
Small holes drilled into each ovary using needlepoint diathermy
Aim to reduce LH and restore feedback mechanisms
Successful in 50% and lasts 12-18 months
When are gonadotrophins indicated for subfertility?
For clomifene-resistant PCOS or low oestrogen with normal FSH
Injected, expensive and needs USS monitoring
