Investigation & treatment of infertility Flashcards
What physiological events are required for conception?
- ovulation
- spermatogenesis
- intercourse
- ejaculation
- fertilisation
- implantation
What is the NICE definition for an infertile woman?
A woman of reproductive age who has not conceived after one year of unprotected sexual intercourse
What causes subfertility?
- Male factor
- Anovulation
- Tubal factor
- Subtle factors that are not detectable on routine investigation.
What is the difference between infertility and subfertility?
Infertility: inability to achieve a pregnancy
Sub-fertility: any form of reduced fertility with a prolonged time of unwanted non-conception
Define primary & secondary infertility
- Primary infertility:someone has never achieved a pregnancy before
- secondary infertility: someone has had a pregnancy before ( baby,miscarriage, T.O.P included). For example, it could be after an ectopic pregnancy where you have a Fallopian tube removed
What various risks of tubal disease exist?
- STI
- ectopic
- surgery
- history of endometriosis
What is the effect of smoking on fertility?
- Reduces women’s fertility
- Reduces semen quality
What factors may contribute to male infertility
- smoking
- drugs (therapeutic& recreational)
- occupation
- testicular maldescent
- trauma
- infections( STI,mumps orchitis)
- surgery
- Radiotherapy
- Congenital
What is testicular maldescent?
- A condition in which one or both of the testicles don’t move all the way down into the scrotum
- A lot of the time this doesn’t get recognized till their 7-9 yrs and in that time they would’ve had significant damage to their spermatogenesis
What basic investigations are used to investigate infertility?
- Ovulation
- semen fluid analysis
- pelvic anatomy and tubal patency
- ovarian reserve
How can we assess the pelvic anatomy and fallopian tubes patency?
- Laparoscopy& dye: Gold standard in tubal patency evaluation. You inject the dye through the cervix and visualize the dye coming from the fallopian tubes
- Hysterosalpingogram (HSG):a radiologic procedure to investigate the shape of the uterine cavity and the shape& potency of the fallopian tubes
- Hystero contrast sonogram (Hycosy): ultrasound procedure, a dynamic test to investigate the fallopian tubes.
What is the significance of ovarian reserve
- The number & quality of oocytes decline with a woman’s age,as does her overall fertility
- Measures to assess ovarian reserve are used to predict the likelihood of a successful response to ovarian stimulation with assisted reproduction treatment, although it seems to have a poor correlation with pregnancy outcomes
- Testing for ovarian reserve is mainly a measure of quantity but also reflects the quality of the oocytes
- A woman’s age at the time of treatment= the best predictor for oocyte quality
What can we use to predict the ovarian reserve?
- Early follicular FSH (reflects what the pituitary is doing in response to the number of eggs). An elevated value is highly sensitive for identifying women with a depleted ovarian follicular pool
- AFC: best checked in the early follicular phase; inter-observer variability; correlates well. Good accuracy for predicting poor response in regularly cycling women but not a good test for pregnancy prediction
- AMH: produced by the granulosa cells, from the pre-atral and antral follicles; can be measured anytime in the cycle and intercycle varibility is reported to be low; accurately measured in women receiving hormonal contraception
- Response achieved during an ART( Assistive Reproduction Technology-e.g IVF) may be the best predictor for ovarian reserve
What other investigations may be useful when investigating infertility?
- Day 2-4 hormone profile (FSH,LH,PROLACTIN,TSH,TESTOSTERONE)
- Rubella
- cervical smear
- chlamydia swabs
- viral serology (Hep B. Hep C, HIV)
What treatment options are available for infertility?
- Laparoscopy
- Assisted conception
- ICSI (Intracytoplasmic Sperm Injection)
