Infertility (Male and Female) Flashcards
(37 cards)
Define infertility
Inability to conceive after 12 months of regular (once every 2-3 days ) unprotected sexual intercourse
Primary - no pregnancy before
Secondary - children w/ current or previous partner
How does age affect fertility?
Decline in oocyte population and eggs inherent quality. Increased risk of spontaenous miscarriage and genetically abnormal offspring
pronounced decline from 37
steep decline after 40
What are causes of infertility?
Ovulation defects (25%)
Male factor (30%)
Tubal disease (20%)
Unexplained infertility (25%)
other:
Endometriosis
Uterine factors (abnormalities)
Other
What are causes of anovulation?
PCOS
Weight related BMI >30 / <18
Ovarian failure - premature ovarian insufficiency ( secondary cause of this could be a pt on chemo/ radiotherapy)
Hyperprolactinaemia
What is a cause of tubal disease?
PID - blocking tube or damaging function of tube
How do you diagnose infertiliy?
Diagnosis is one of exclusion
Identify :
1) clear cause
2) possible cause
3) unexplained cause
In a woman with suspected infertility what points do you want to cover in the history and why?
1) Age
- oocyte number and quality
2) Duration of fertility
3) Type of infertility
- is it secondary infertility - do the couple independently have children?
4) Menstrual cycle - ovulating?
Flow / pain associuated / IMB / PCB
5) Tubal surgery / PID?
- cause adhesions
6) Menorrhagia / dysmenorrhoea / pelvic pain
- e.g endometriosis
7) hx of pelvic surgery - adhesions
8) Hx of STIs
9) Smoking / alcohol / Drug history / PMHX
10) Sex - how often, erectile dysfunction / stress etc
What are you looking for on examination of a woman w/ possible infertility ? Why?
1) BMI
-Low or high can cause infertiliy e.g. low BMI and extreme exercise causing 2 amenorrhea and anovualtion.
2) Body hair distribution
- look for signs of hyperandrogenism -PCOS
3) Galactorrhoea
- breast exam sign of prolactinaemia due to pituitary tumour
4) Secondary sexual characteristics
- primary or secondary cause of amenorrhorea
5) Pelvic examination
- structural abnormalities
- fixed or tender uterus (another card for details of this)
You are examining a woman with suspected infertility.
1) Walk through how and what will examine
2) What bedside investigations might you do while there?
1)
- Examine vulva, vagina and cervix with speculum - looking for structural abnormalities
- Do : bimanual pelvic examination looking for:
fixed (fixed retroverted uterus - endometriosis / adhesions), tender uterus or masses (fibroids)
2) While have your speculum do:
-genital swabs (HVS and chlaymidia)
- cervical smear if not done
Seeing a male pt for infertility
What do you want to cover in the history and why?
1) general health
2) alcohol and smoking
3) Previous surgery
- inguinal hernia, undescended testes
4) Previous infection
- TB, mumps as an adult
5) Sexual
- ejaculatory / erectile dysfunction
- frequency of sex
6) Drug hx / PMHx
What might you to include when examining a male pt for infertility?
- normla secondary sexual characterisics
- gynaemastia?
- Scrotum (look for varicocele)
- testicular size
- testicular positon (undescended)
- Prostate - rectal exam for chronic infection prostatitis
How can you divide causes of male factor infertility?
Pre-testicular
Testicular
Post testicular
What are some pre-testicular causes of male infertility?
Pathophysiology: Testosterone is needed for sperm (HPA axis controls testosterone) Having LOW LH and FSH (hypogonadoptrophic hypogonadism) and LOW TESTOSTERONE can be due to:
- Pituitary gland or hypothalamus pathology
- Suppression - stress or chronic conditions e..g hyperprolactintaemia
- Kallman syndrome
What are some testicular causes of male infertility?
Testicular damage from:
* Mumps
* Undescended testes
* Trauma
* Radiotherapy
* Chemotherapy
* Cancer
Genetic / congenital = defective / absent sperm production:
* Klinefelter syndrome
* Y chromosome deletions
* Sertoli cell-only syndrome
* Anorchia (absent testes)
What are some testicular causes of male infertility?
Obstruction preventing sperm being ejaculated can be caused by:
- Damage to the testicle or vas deferens from trauma, surgery or cancer
- Ejaculatory duct obstruction
- Retrograde ejaculation
- Scarring from epididymitis, for example, caused by chlamydia
- Absence of the vas deferens (may be associated with cystic fibrosis)
- Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)
How would you investigate female infertility?
Baseline tests:
Bedside
* Chlaymidia screening (HIV Hep B, C need to be tested beofre see specialist)
Bloods / lab:
* Baseline hormonal profile: Day 2 FSH and LH
* TSH
* Prolactin
* Testosterone levels
* anti-mullerian hormone
* rubella status (vaccinate if not immune)
* Mid luteal phase progesterone to confirm ovualting (day 21 or 7 days before next expected period)
Imaging:
* TVUS - adnexal massesm fibroids, endometrial popyls, PCOS
* Hysteroscopy for uterine cavity abnromalities
* Test of tubal patency (will expand later slides)
What tests would you do to test tubal patency in a woman with infertility?
Hsyterosalpingography (HSG)
* xray imaging and contrast injected through cannuala in cervix to show uterine anatomy and tubal patency
* SE: period like cramps and tubal spasm
* caution: do once chlyamdia swabs -ve and give azithromycin 1g PO
Diagnostic laparoscopy and dye
* day case
* gold standard for tubal patency
* dye injecte thorugh cervix while tubes visualised with laproscope.
* advantage: can treat pelvic pathology at the same time
You are going to test tubal patency of a woman with infertility.
- When would diagnositc laparoscopy and dye be first line?
- If strong suspicion of tubal abnormality e.g. Hx of PID, endometriosis/ previous surgery
Otherwise: would be second line and done is the HSG (hysterosalpingography) abnormal
What investigations would you do for a man being investigated dor infertility?
- Semen analysis x 2
Lab:
* FSH (plasma FSH raised in testicular failure)
* LH (+testosterone if suspect androgen insufficiency)
* Testosterone
* Genetic testing (karyotype to exclude 47 xxy and cystic fibrosis screen)
Imaging
* transrectal US seminal vesicles , prostate (if aspermia or low sperm count)
* Vasography, which involves injecting contrast into the vas deferens and performing xray to assess for obstruction
other
* Testicular biopsy
What are normal values of sperm analysis according to WHO?
- Semen volume (more than 1.5ml)
- Semen pH (greater than 7.2)
- Concentration of sperm (more than 15 million per ml)
- Total number of sperm (more than 39 million per sample)
- Motility of sperm (more than 40% of sperm are mobile)
- Vitality of sperm (more than 58% of sperm are active)
- Percentage of normal sperm (more than 4%)
When testing sperm for infertility the results are below normal range. What shoud you do?
Borderline:
* repeat in 3 motnhs
Abnormal:
* repeat 2-4 weeks
Lifestyle changes, mulitvitamin with selenium, zinc and vitamin C
What advice should men be given before providing a sample of sperm?
- Abstain from ejaculation for at least 3 days and at most 7 days
- Avoid hot baths, sauna and tight underwear during the lead up to providing a sample
- Attempt to catch the full sample
- Deliver the sample to the lab within 1 hour of ejaculation
- Keep the sample warm (e.g. in underwear) before delivery
What factors affect sperm quality and quantity?
lifestyle:
- Hot baths
- Tight underwear
- Smoking
- Alcohol
- Raised BMI
- Caffeine
What are different results you can get when examaining semen?
- Polyspermia- lots of perm (more than 250 million per ml).
- Normospermia - normal characteristics of the sperm
- Oligospermia- reduced number of sperm. it is classified as:
1. Mild oligospermia (10 to 15 million / ml)
2. Moderate oligospermia (5 to 10 million / ml)
3. Severe oligospermia (less than 5 million / ml) - Cryptozoospermia-very few sperm in the semen sample (less than 1 million / ml).
- Azoospermia - absence of sperm
