Infertility/fertility Flashcards
(30 cards)
Primary vs secondary infertility
Primary - couple never been able to conceive
Secondary - couple cannot get pregnant again, previously could w/o difficulty
What are the general causes of intertility?
- Male infertility - 30%
- Ovulatory disorders - 25%
- Tubal damage - 20%
- Uterine or peritoneal disorders - 10%
- No identifiable cause
What is general advice to couples trying to conceive?
- Sexual intercourse every 2-3 days throughout womens cycle
- Prep for pregnanct eg. preconceptual folic acid
- Smoking cessation for both parties
- Avoid drinking excessive alcohol
- Women aim for BMI 19-25
What factors affect natural fertility?
- Increasing age
- Obesity
- Smoking
- Tight fitting underwear - maes
- Excessive alcohol consumption
- Ilicit drug use
What are some ovulation/endocrine disorders causing infertility?
- PCOS
- Pit tumour
- Sheehan’s syndrome
- Hyperprolactinaemia
- Cushing’s
- Premature ovarian failure
What are some of the tubal and uterine abnormalities causing infertility?
Tubal - congenital anatomical abnormalities and adhesions following PID
Uterine - bicornate uterus, fibroids, adhesions of the uterus
What are the ix into infertility carried out in primary care?
- BMI, low = anovulation, high = PCOS
- Chlamydia screen
- Semen analysis
- Female hormonal testing
- Rubella immunity
What is involved in female hormonal testings?
- Serum LH and FSH day 2 to 5 of cycle
- Serum progesterone on day 21 or 7 days before end
- Anti Mullerian hormone
- TFTs
- Prolactin when sx of amenorrheoa and galactorrhea
How are female hormonal tests interpretted?
- High FSH = poor ovarian reserve, pit gland producing extra FSH to attempt to stim follicular development
- High LH = PCOS
- Rise of progesterone on day 21 = ovulation occurred and corpus luteum formed and secreting progesterone
- Anti Mullerian hormone - marker of ovarian reserve, high = good
What ix into infertility are carried out in secondary care?
- US pelvis, look for polycystic ovaries or structural abnormalities of uterus
- Hysterosalpingogram
- Laparoscopy and dye - patency of fallopian tubes, adhesions, endometriosis
What is a hysterosalpingogram?
Scan to assess shape of the uterus and patency of the fallopian tubes.
Tubal cannulation under XR guidance can be performed during the scan to open tubes = increase rate of conception.
Contrast into uterine cavity and fallopian tubes. Risk of infection - prophylactic abx and screen for STI.
What is the management of anovulation?
- Weight loss if overweight pt w PCOS
- Clomifene and letrozole stim ovulation
- Gonadotropins stim ovulation if resistant to clomifene
- Ovarian drilling (punctures holes in ovaries using diamthermy or laser = improve hormones = ovulation)
- Metformin
What is clomifene?
Anti oestrogen - selective oestrogen receptor modulator. Give on day 2 to 6. Stops neg feedback of oestrogen on hypothalamus = increase GnRH = increase FSH and LH.
What is the management of tubal factors that cause infertility?
- Tubal cannulation during hysterosalpingogram
- Laparoscopy to remove adhesions or endometriosis
- IVF
What is the advice for men providing a semen sample?
- Abstain from ejaculation for at least 3 days
- Avoid hot baths, sauna and tight underwear
- Attempt to catch the full sample
- Deliver the sample to the lab w/i 1 hour of ejaculation
- Keep the sample warm
What are some abnormal sperm results?
Polyspermia - high number of sperm in semen sample = >250 million/ml
Oligospermia - reduced number, mild = 10-15 mil/ml, mod = 5-10mil/ml, severe = <5mil/ml
Cryptozoospermia - <1mil sperm/ml
Azoospermia - no sperm in the semen
What are normal sperm results?
Normospermia:
- >1.5ml of semen
- pH >7.2
- Conc >15mil/ml
- Total number = >39 mil per sample
- >40% mobile and >58% active
What are some pre testicular causes of infertility?
Hypogonadotrophic hypogonadism = reduced testosterone which is necessary for sperm:
- Pathology of pit gland or hypothalamus
- Suppression due to stress, chronic conditions or hyperprolactinaemia
- Kallman syndrome - delayed or absent puberty and impaired sense of smell
What are the testicular causes of infertility?
Acquired damage - mumps, trauma, RT and chemo, cancer, cryptochidism
Genetic or congenital disorders - Klinefelter syndrome, Y chromosome deletions, Sertoli cell only sydrome, anorchia
What are some post testicular causes of infertility?
- Ejaculatory duct obstruction
- Retrograde ejaculation
- Scarring from epididymitis eg. chlamydia
- Absence of vas deferens
- Damage - trauma, surgery, cancer
How do you investigate abnormal semen analysis?
- Hormonal analysis w LH, FSH and testosterone
- Genetic testing
- Further imaging eg. transrectal US or MRI
- Vasography - inject contrast into vas deferens
- Testicular biopsy
What is the management of male factor infertility?
- Surgical sperm retrieval if obstruction
- Surgical correction of obstruction
- Intra uterine insemination
- Intracytoplasmic sperm injection - sperm directly into cytoplasm of egg
- Donor insemination
What is involved during one cycle of IVF?
- Suppress natural menstrual cycle
- Ovarian stim
- Oocyte collection
- Insemination/intracytoplasmic sperm injection
- Embryo culture and then transfer
How is the natural menstrual cycle suppressed?
- GnRH agonist protocol - injection during luteal phase, 7 days before expected onset of period, stim pit gland to secrete FSH and LH, negative feedback on hypothalamus due to surge = reduction in natural GnRH = suppress menstrual cycle
- GnRH antagonist protocol - daily SC injectoin eg. cetrorelix, from day 5-6 of ovarian stim. Suppresses LH so no ovulation.
(want follicles to be made but not released as want to collect them)
