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Flashcards in Subfertility Deck (13):
1

Hx and investigstion should address

1. Ovulation - is the woman ovulating? if not why?
2. Ovarian reserve - good / satisfactory / poor / diminished
3. Tubes and transport - problem with tubes?
4. Sperm - present in the ejaculate? if not / reduced then why?

2

PCOS: Rotterdam consensus

2 out of 3:
Clinical hyperandrogenism or biochemical hyperandrogenism (elevated total / free testosterone)
Oligomenorrhoea (less than 6-9 per year)
Polycystic ovaries on ultrasound (>= 12 antral follicles on one ovary or ovarian volume >= 10cm cube)

3

Symptoms

Hirsutism, acne, obesity, irregular menses / amenorrhea (leading to subfertility)

Features: elevated LH and insulin resistance

Leads to ovarian growth, ovarian cyst formation and androgen production.

4

Tests

Serum testosterone (increased)
LH (increased) and FSH (decreased)
Prolactin, TFTs
Pelvic ultrasound is essential

5

Tx

OCP: suppress androgen, decrease testosterone and LH
Weight loss
If pregnancy desired: metformin and clomiphene (anti-oestrogen which encourages FSH secretion by the pituitary and hence ovulatory cycles)

6

Clomiphene

Started on day 2-6 of the cycle
First cycle monitored using ultrasound to monitor follicle development and reduce the risk of multiple pregnancies
Mid-luteal progesterone taken - if low then dose must be increased

7

Interpretation of serum progesterone

< 16 - if consistently low then refer to specialist
16 - 30 - repeat
> 30 - indicates ovulation

8

Tubal and uterine factors

Possible to assess tubal patency:
No suggestion of tubal damage - hysterosalpingography (x-ray after injecting radio-opaque dye)
Suggestion of damage to tubes - laparoscopy and dye (opportunity to divide adhesions if found)

If tubal abnormalities - best chance of conception is IVF

9

Pre-conception advice

Optimal management of pre-existing medical conditions
BMI 19-30
Stop smoking
Stop any illicit drug use
Limit alcohol consumption
Intercourse: advise at least every 2 days from 6 days prior to presumed day of ovulation until 2 days after
Folic acid
Keep up to date on cervical smears
Ensure full immunisation against rubella

10

Ovarian Hyperstimulation Syndrome

Complication seen in some forms of fertility tx
High levels of vasoactive substances such as VEGF - increased membrane permeability and loss of fluid from the intravascular compartment
Rarely seen with clomifene, more likely with gonadotrophin or hcg treatment

Management - monitoring, fluids, thromboprophylaxis and paracenteses

11

Severity

Mild - abdominal pain and bloating

Moderate - abdominal pain and bloating, nausea and vomiting, ultrasound evidence of ascites

Severe - as for moderate + clinical evidence of ascites, oliguria, haematocrit > 45%, hypoproteinaemia

Critical - as for severe + thromboembolism, acute respiratory distress syndrome, anuria, tense ascites

12

Prem Ovarian Failure

Onset of symptoms and elevated gonadotrophins before the age of 40

1 in 100

Idiopathic, chemo, radio, autoimmune

Hot flushes, night sweats, infertility, secondary amenorrhoea, raised FSH and LH

13

Definitions

Asthenospermia - low motility
Teratozoospermia - reduction in number of sperm that look normal
Oligozoospermia - reduced number of sperm