Subfertility (Complete) Flashcards
Define subfertility
Diminished ability for a couple to conceive
Most couples are able to conceive with regular sexual intercouse (3-4 times per week) within which timeframe?
1 year
80%
What are causes of infertility?
Genetic syndromes:
- Kleinfelter’s syndrome
- Turners syndrome
Endocrine disorders:
- PCOS
- Premature ovarian failure
- Pituitary tumours
- Sheehan’s syndrome
- Cushing’s syndrome
Female genital abnormalities:
- PCOS
- Premature ovarian failure
- PID (adhesions)
- Bicronate uterus
- Fibroids
- Asherman’s syndrome
- Cervical damage (e.g. LLETZ)
Male genital abnormalities:
- Cryptochordism
- Varicocele
- Testicular cancer
- Congenital testicular defects
- Retrograde ejaculation
- Premature ejaculation
What general factors may contribute to increased risk of infertility?
Increasing age
Obesity
Smoking
Tight-fitting underwear (males)
Excessive alcohol use
Illicit drug use
Steroids
What is the referral criteria for couples unable to conceive despite normal investigation findings?
Woman under 36 years:
Refer if unable to conceive after 1 year of regular sexual intercourse and normal examination/investigation findings
Woman over 36 years:
Refer if unable to conceive after 6 months of trying to conceive
When is earlier referral indicated?
What investigations should be conducted if subfertility is suspected in woman?
Bedside:
Bimanual and speculum examination: Check for physical abnormalities (e.g. large fibroid)
STI screen
Bloods:
Serum progesterone testing (7 days before end of menstrual cycle)
LH/FSH: Check for primary ovarian insufficiency/PCOS
Anti-mullerian hormone (AMH): Check ovarian reserves
TFTs
Imaging:
Transvaginal US
Hysterosalpingography
Laparoscopy and dye
When in the menstrual cycle is serum progesterone testing indicated?
Indicated 7 days before end of menstrual cycle
7 days before period starts
What findings are considered normal in serum progesterone testing?
Rise in progesterone
Suggests formation of corpus luteum and hence ovulation has occured
What is hysterosalpingography?
Type of procedure using contrast to detect tubal patency
What is the purpose of laparoscopy and dye procedure?
Assess tubal patency in presence of co-morbidities (e.g. PID, ectopic pregnancy, endometriosis).
Involved laparoscopically injecting dye into uterus to assess for patency
What investigations should be considered in males with suspected subfertility?
Bedside:
Testicular examination: Check for anomalies
Semen analysis: check sperm count, motility and morphology
Bloods:
Serum testosterone
LH/FSH
TFTs
What is the management plan for couples with subfertility?
Conservative:
Alter modifiable risk factors:
- Weight loss
- Smoking/alcohol cessation
- Stress-reduction strategies
Medicine:
Treat underlying causes
Ovulation induction:
- Clomiphene
- FSH and LH injections
- GnRH or DA agonists
Surgical:
IVF or intracytoplasmic sperm injection: If infertile > 2 years
When can couples be referred for IVF or intracytoplasmic sperm injection?
If unable to conceieve within 2 years
What medication can be considered to promote fertility by inducing ovulation?
Clomiphene
FSH/LH injections
GnRH or DA agonists
