Subfertility Flashcards

(34 cards)

1
Q

What is subfertility?

A

Inability to conceive after 1 year of unprotected intercourse

Primary = never been pregnant

Secondary - been pregnant before

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2
Q

Statistics of subfertility

A

80% couples conceive <12 months

90% within 2 years

10-15% British couples affected by subfertility

Fecundity (probability of conceiving each month) reduces with age

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3
Q

Causes of subfertility

A

Many couples have both M&F factors

15% idiopathic

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4
Q

Female factors of infertility

A

1) Tubal problems: 20%

  • PID, ectopic, endometriosis

2) Chlamydia

  • Can cause PID

3) Endometrioma

  • Presence of endometrial tissue in and on ovary
  • Affects 17-44% people with endometriosis

4) Fibroids

5) Polyps

  • overgrowth of enometrial cells can cause infertility if they disrupt the uterine lining and impede implantation

6) Anovulation (25%)

  • Ovaries do not release oocyte during mestrual cycle
    7) Uterine anomalies
  • Congenital or acquired
  • Failure of Mullerian duct fusion resulting in uterine malformations e/g/ bicornate uterus and uterine septum
  • Ashermann’s syndrome
  • Fibroids
    8) Cervical anomalies
  • Infection, surgery
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5
Q

Categories of anovulation

A

WHO classifies anovulation based on serum gonadotrophin levels (FSH and LH)

WHO 1: hypogonadotrophic hypogonadism

  • Causes amenorrhoea, low body weight, galactorrhoea
  • Low FSH, low LH, low oestroadiol, high prolactin
  • Due to inadequate GnRH secretion from pituitary or problem with hypothalamus

WHO 2: normogonadotrophic normoestrogenic

  • Oligo or amenorrhoea, high body weight, hirsutism, acne
  • Most common, most commonly due to PCOS
  • Diagnosis according to revised Potter criteria: oligo/ anovulation, hyperandrogenism, PCOS on USS
  • FSH and LH in normal range, high LF:FSH ratio, high testosterone

WHO 3: hypergonadotrophic hyperoestrogenic

  • Usually an indication of ovarian failure, presents with hot flushes
  • High LH, high FSH, low oestradiol, high TSH and low T4, Tuner’s syndrome, fragile X

Causes: genetic (Tuner’s), xRT, smoking

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6
Q

Most common cause of female infertility?

A

Anovulation - age and PCOS most common in UK

In the world it is tubal disease

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7
Q

Management of anovulation

A

WHO 1: weight gain, indice ovulation, treat prolactinoma with bromocriptine

WHO 2: lose weight, induce ovulation, ovarian drilling

WHO 3: HRR, donor oocytes needed if patient wants to undergo fertility treatment

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8
Q

What is a hysterosalpingogram?

A

Infection of radio opaque dye into cervix

Normal reult shows filling of uterine cavity and filling of fallopian tubes bilaterally

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9
Q

How can chlamydia cause infertility?

A

Infection can spread and cause PID

Fitz-Hugh-Curtis syndrome can also occur where PID causes swelling of the tissue around the liver

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10
Q

Types of fibroids

A

Intramural: most common, inside muscle

Subserosal: outside womb into pelvis

Submucosal: grow into womb cavity

Submucosal fibroids can affect fertility but unlikey that subserosal will

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11
Q

Investigations for subfertility

A

General: BMI, signs of PCOS

Pelvic examination: massess, endometriosis (fixed + painful uterus), cervical smeal, chlamydia screen

Urinary LH: + test indicates imminent ovulation

Baseline (cycle day 2-5) hormone profile

Mid luteal progesterone to confirm ovulation

Secondary care: transvaginal USS to look for PCOS, fibrids, endometriomas

Hysterosalpingogram

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12
Q

Trend of male sperm over the last 50 years

A

Parameters have been declining over the last 50 years and sperm of aging men have serious health implications for children

Oxidative damage to sperm DNA

Increased neurological conditions: sutism, BPD

Cleft palate, diaphragmatic hernia, heart malformations

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13
Q

Terms used to describe sperm parameters

A

Aspermia = absence of sperm

Azoospermia = absence of sperm

Oligozoospermia = low sperm count

Asthenozoospermia = poor motility

Teratozoospermia = morphological defects

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14
Q

Causes of male subfertility

A

Semen abnormality = 85%

  • low count, poor motility, morphological defects
  • Testicular cancer, drugs/ alcohol, varicocele

Aspermia = 5%

  • Pretesticular: anabolic steroid use, idiopathic hypogonadotrophic hypogonadism, Kallman’s, pituitary adenoma
  • Non-obstructive: cryptochordism, orchitis, Klienfelter’s, chemo, xRT
  • Obstructive: congenital bilateral absence of vas def (CF), chlamydia, gonorrhoea

Immunological

  • Antisperm antibodies/ infection

Cortical dysfunction

  • Mechanical cause with normal sperm function e.g. hypospadias, phimosis, retrograde ejactulation, failure to ejactulate
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15
Q

Causes of retrograde ejaculation

A

DM, spinal cord injury, phenothiazines

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16
Q

WHO criteria of normal ejaculate

A

Volume >1.5mL

Concentration >15x10*6/mL

Progressive motility >32%

Total motility >40%

Normal morphology >4%

17
Q

What is Kartagener’s?

A

Rare, autosomal recessive genetic ciliary disorder comprising the triad of situs inversus, chronic sinusitis, and bronchiectasis

Consider in a patient with hx of sinusitis, ear infections and bronchitis

18
Q

Process of semen analysis

A

Male provides sample after 2-4 days no ejaculation

If any of the WHO criteria re abnormal second sample given 3 months later to exclude temporary illness

66% time no cause is found

19
Q

Investigations for male infertility

A

FSH elevated: testicular failure

Karyotype: exlude Klienfelter’s

Cystic fibrois screen

Semen fructose test: fructose is sperm food, no fructose suggest obstruction

Low LH and low testosterone = hypogonadotrophic hypogonadism - MRI done to rule out lesion in hypothalamus or pituitary

Doppler: varicocele

20
Q

What is Klinefelter’s?

A

47 XXY

Males who have an additional copy of the X chromosome

Primary features = infertility

Can also cause less body hair, breast growth

Weak muscles as babies and children

Broader hips

Associated with learning difficulties

21
Q

What is Kallmann syndrome?

A

Defined by delay/ absence of puberty + anosmia

Due to isolated FSH/ LH deficiency - failed GnRH activity

More common in males but also occurs in females

22
Q

Medication to induce ovulation

A

1) Clomifene citrate: antioestrogen, blocks negative feedback of oestradiol to pituitary thus increasing FSH secretion and folliculogenesis
2) Metformin: insulin sensitiser, reduces insulin levels, androgen levels, increases ovulation rates when combined with clomifene citrate
3) Letrozole: aromatase inhibitor, decreases oestrogen production by ovarian granulosa cells therefore decreases negative feedback on pituitary and increases FSH production and folliculogenesis
4) hMG or FSH + LH: gonadotrophins, stimulates folliculogenesis
5) Ovarian drilling: diathermy, enables spontaneous ovulation

23
Q

Surgery to treat infertility

A

Tubal surgery offered to women >37yrs with mild tubal disease

Women with moderate - severe tubal disease are referred for assisted conception

  • Hydrosalpinges (fluid in tubes) removed 1st)
  • Ablation of endometriosis deposits
24
Q

Treatment of male inferility

A

IVF/ ICSI

MESA: microsurgical epididymal sperm aspiration

PESA: percutaenous

TESE: testicular sperm extraction

TESA: percutaneous testicular sperm aspiration

25
How is PCOS-related subfertility managed?
Ovarian drilling if clomifene citrate not working
26
What is super ovulation/ controlled ovarian hyperstimulation?
Process used to promote release of \>1 egg per month Used for women with hypogonadotrophic hypogonadism or PCOS Daily injections of FSH from day 3-5 promotes follicle growth When biggest follicle reaches 17mm an injection of hCG given to induce ovulation + planned intercourse
27
What is the single most important predictor of IVF success?
Woman's age Most centres in the UK don't go above 43yrs with number of embyros transferred based on age \<37: 1-2 depending on attempt 37-39: 1-2 depending on attempt 40-42: 2
28
Stages of IVF
**1) Ovarian hyperstimulation:** GnRH agonist used to achieve pituitary down regulation and promote ovulation. Daily FSH or hMG (LH+FSH) to promote follicular development. Pelvic USS from day 8 then every 2 days after to look for follicles, hCG injection given when lead follicle = 18mm **2) Oocyte recovery:** USS guided transvaginal oocyte recovery is carried out 34-36hrs after hCG administration **3) Insemination:** on day of oocyte recovery the male given semen sample which is added to petri dish with oocyte and 50-70% are fertilised within 24hrs **4) Embryo culture and transfer:** 1-2 fertilised oocytes selected for transfer, the rest are frozen Day 3-5 1-2 embryos are transferred to uterus under USS **5) Luteal phase support:** progesterone supplementation used to support the pregnancy until 10 weeks when placenta starts to make own progesterone
29
How is ICSI different from IVF?
ICSI: sperm injected into egg rather than letting them do their thing in the petri dish ICSI is used in 50% IVF
30
What is pre-implantation diagnosis?
1-2 cells removed from each embryo and genetically tested to screen for disabling conditions
31
Risks of IVF
Risks to mother - Ovarian hyperstimulation syndrome: affects 7%, 1% severe RFs: low BMI, PCOS, young Usually presents 2-3 days after oocyte recovery, associated with capillary leakage leading to pleural effusion, pericardial effusion, ascites, intravascular volume depletion Treatment: fluids, thromboprophylaxis, fluid drainage Foetus: increased risk of multiple pregnancy
32
Success rate of IVF
25% overall 32% if \<35
33
IVF in layman terms
Suppress normal cycle then stimulate ovaries via daily hormone injections When ovaries look ready a final injection given to make eggs mature Eggs collected and mixed with sperm Fertilised egg implanted into womb Any spares are frozen
34
What can be measured @ day 28 of the cycle to check if woman has ovulated?
Progesterone