Infertility Flashcards
Infertility:
a) Primary
b) Secondary
a) Not conceived from regular sex without contraception for 12 months
b) Previously conceived, now 12 months without despite regular sex and no contraception
Advice for couples trying to conceive:
a) Sex-related
b) Lifestyle - maternal? paternal?
a) Every 2-3 days, no contraception use
b) Reassure and support
- Mother - folic acid, no smoking, healthy BMI, no alcohol, no teratogens (e.g. methotrexate, warfarin, valproate, lithium), no antipsychotics (hyperprolactinaemia), no NSAIDs
- Father - no smoking, moderate alcohol, keep testicles cool (loose fitting pants, regular breaks from sitting, stand outside), healthy BMI, avoid certain drugs (anabolic steroids, marijuana, opioid narcotics, cocaine and methamfetamines)
Female infertility: causes
a) Ovulation disorders - most common? Three types
b) Structural - causes
c) Important components to include in history
d) Important symptoms to ask about
a) HP dysfunction (e.g. anorexia causing amenorrhoea, hyperprolactinaemia), HPA dysfuntion (PCOS - most common cause), Ovarian failure (premature menopause, Turner’s)
b) Tubal (PID, endometriosis, previous ectopic, previous TOP), Uterus (bicornuate, submucosal fibroids), Cervix (too short, too much mucus)
c) Menstrual Hx, Sexual Hx (including any STIs), cervical smear history, history of miscarriages/previous pregnancies, any autoimmune diseases (SLE, etc.)
d) Dyspareunia, pelvic pain, PV discharge, menstrual changes, systemic symptoms (thyroid, etc.), virilism
Female infertility: main causes
a) Athlete, amenorrhoea
b) Pelvic pain, dyspareunia, dysmenorrhoea
c) Acne, obesity, hirsutism
a) Anorexia - Hypothalamic dysfunction
b) Endometriosis
c) PCOS
Female infertility: initial investigations
a) Clinical examiations
b) Bloods and others
c) Secondary care investigations
a) Appearance (PCOS), abdo (fibroids, cysts), bimanual (cysts, endometriosis, PID, vaginismus)
b) Day 21 (mid-luteal) progesterone, Serum FSH and LH, testosterone/SHBG, prolactin. HVS for chalmydia/gonorrhoea
c) Tubal patency tests (hysterosalpingogram [HSG] or laparoscopy and dye), USS ovaries (PCOS), laparoscopy for endometriosis, Ovarian reserve test (AMH levels or antral follicle count)
Male infertility: causes
a) Low sperm count is AKA..? (define)
b) 5 modifiable causes of subfertility in males
c) Genetic disorders
d) Congenital problems
e) Testicular causes
f) Pituitary causes
g) Sexual causes
h) Prescription drug causes
a) Oligozoospermia: < 15 million sperm/mL
b) Smoking, excess alcohol, BMI > 30, balls too hot, use of certain recreational drugs (e.g. anabolic steroids, cannabis, amphetamines, cocaine)
c) Klinefelters, Kallmans, Testicular feminisation
d) Cryptorchidism, hypospadias
e) Varicocoele, testicular tumour, trauma, vasectomy, chemoradiotherapy or surgery
f) Pituitary tumour, Cushing’s, hyperprolactinaemia
g) ED, ejaculation dysfunction
h) SSRIs/BBs/spironolactone (ED), steroids, phenothiazines (prolactin)
Male infertility: investigations
a) Examinations
b) Main test - how? repeat?
c) If indicated, what bloods?
d) If ejaculatory disorder suspected, screen for…?
e) Other tests
a) Height, weight, testicular (swelling, varicocele, size)
b) Semen analysis (after 3 days abstinence), if normal no repeat, if abnormal repeat at 3 months
c) Hormones - testosterone, FSH, +/- LH and prolactin
d) Diabetes - fasting glucose
e) Testicular biopsy, USS testes, STI screen
Reassuring statistics to tell patients who are struggling to conceive
- Over 80% of couples should conceive within a year if the woman is aged under 40 and they are having regular unprotected sexual intercourse.
- Of those who do not conceive within a year, half will conceive within the next year (so 90% over two years).
Infertility: general management
a) Lifestyle
b) Psychological
a) Smoking, BMI, alcohol, folic acid (women), keep balls cool (men), no teratogens (women) or drugs reducing fertility (including those causing ED, in men)
b) Couples therapy, fertility support group
Male infertility: management
c) Low sperm count
d) Hypogonadic hypogonadism
e) Cryptorchidism
c) Conservative (as above), if obstructive - surgery (not surgery for varicocele)
d) Gonadotrophins (GnRH)
e) Orchidopexy
Female infertility: management
f) Group 1 ovulation disorders (hypothalamic)
g) Group 2 ovulation disorders (HPA) - i.e. PCOS
h) If hyperprolactinaemic
i) Ovarian failure
j) Tubal blockage/damage
k) Endometriosis
l) If all else fails…?
f) Normalise BMI, moderate exercise (i.e. reduce if excessive), GnRH
g) 1st line: weight loss.
2nd line: Clomifene +/- metformin
h) Dopamine agonist (e.g. bromocriptine)
i) Ovarian hyperstimulation (e.g. clomifene)
j) Surgical correction
k) Surgical - remove lesions, etc.
l) Assisted conception - IVF, ICSI, donor sperm/eggs
IVF:
a) Criteria (age)
b) Treatment before
c) Treatment after
d) Main acute complication - how does it present?
e) Other possible complications related to…?
a) 3 cycles for those < 40 (1 cycle for > 40 if no previous IVF)
b) Ovarian stimulation (hCG, GnRH or clomifene)
c) Progesterone
d) Ovarian hyperstimulation syndrome (OHSS): causes nausea, vomiting, diarrhoea, abdominal pain, etc.
e) Multiple pregnancy
