Definition of infertility?
Inability of a couple to conceive after 12 months of regular intercourse without use of contraception
How many couples report infertility issues?
1 in 7
What are the chances of conception?
80% of couples in the general population will conceive within 1 year if: the woman is aged under 40 years and
they do not use contraception and have regular sexual intercourse
What are the main queries as to why they cannot concieve?
Are eggs available?
Are sperm available?
Can they meet?
Can embryo implant?
What questions should the woman be asked during the history?
- Duration of infertility
- Previous contraception
- Fertility in previous relationships
- Previous pregnancies and complications
- Menstrual history
- Medical and surgical history
- Sexual history
- Previous investigations
- • Psychological assessment
What should be examined of the female?
- Weight
- Height
- BMI (kg/m2)
- Fat and hair distribution
- Galactorrhoea
- Abdominal examination
- Pelvic examination
What baseline investigations should be carried out?
- Rubella Immunity
- Chlamydia
- TSH
- sub-clinical hypothyroidism can cause issues with implantation
- Testing for Ovulation
- Regular Period: Mid-luteal phase progesterone 7 days prior to expected period
- Irregular Period: Day 1-5 FSH, LH, PRL, TSH & testosterone
What investigations should be carried out at the fertility clinic?
- Pelvic US
- Physical Exams
- Tubal Patency Test
- Hysterosalpingo-Contrast-Sonography (HyCoSy)
- Laparoscopy
- Test for ovulation
- mid luteal phase progesterone
- Irregular periods require FSH & LH testing to assess
What male investigations should be carried out? And what are the normal reference values for said test?
- Computerised Semen Analysis
- Reference values15-200 million/ml
- <15 million is oligospermia
- <5 million is severe oligospermia
- 0 is azoospermia
- Total sperm count: <39 million= low
- Reference values15-200 million/ml
What are group 1 ovulatory disorders? + treatment?
- Hypo-gonatrophic hypo-gonadial anovulation
- Treatment: Optimise BMI and reduce exercise levels if very high
What are group 2 ovulatory disorders?
- Normo-gonadotrophic, normo-oestrogenic anovulation
- Polycystic Ovary Syndrome
How can we diagnose polycystic ovary syndrome?
Need 2 of the following:
- Androgen Excess
- Hirsutism
- Moderately raised Testosterone
- acanthosis nigricans
- Infrequent periods
- due to Anovulation
- US
What is the treatment for polycystic ovary syndrome?
- Optimise BMI (18-30)
- Clomifene (selective oestrogen receptor modulator, Inhibits oestrogen receptos in hypothalamus, preventing negative feedback, leading to up-regulation of gonadotrophin release, causing ovulation)
- Gonadotrophins
What is the required dose of Clomifene for Polycystic ovarian disease? + side effects?
- Start at 50mg per day
- Follicle scanning to monitor and adjust dose up to 150mg as necessary
- 6 cycles
- Ovarian hyperstimulation
- Multiple pregnancy
- Visual alterations
- Vasomotor “flushes”
What are the indications of use for gonadotrophins for polycystic ovarian disease?
- No ovulation on Clomifene
- Ovulated but still not pregnant after 6 cycles
- Up to 3-6 cycles
What are group 3 ovulatory disorders?
Hyper-gonadotrophic hypo-oestrogenic
What are some other infertility causing female pathologies that are not ovulatory?
- Androgen secreting adrenal tumour
- Signs and symptoms
- Hirsutism
- acanthosis nigricans
- Signs and symptoms
- Prolactinoma
- Fibroids:
- Signs and symptoms
- Pressure Symptoms
- Period problems
- Submucosal
- Affect fertility the most as alter implantation
- Signs and symptoms
- Endometriosis
- Tumours
- Sterilised
- Reversal not offered on NHS
- Unexplained
What is Hirsutism? Common causes? Why is it clinically important to identify?
[condition of unwanted, male-pattern hair growth in women]
Nonclassic congenital adrenal hyperplasia (NCCAH) is a common cause of hirsutism.
Androgen-secreting tumors are rare, particularly in premenopausal women (0.2 percent of women with hirsutism) [13], but 50 percent are malignant at the time of diagnosis.
What should we look for on pelvic examination?
- Masses
- Pelvic distortion
- Tenderness
- Vaginal septum
- Cervical abnormalities
How would fibroids present?
- Period problems
- Pressure symptoms
- Infertility
What issues cause male infertility in relation to epididymus?
STIs: Chlamydia, Gonorrhoea
What causes male infertility in relation to vas deferens?
- Cystic Fibrosis mutations of Vas Deferens
- Congenital Bilateral Absence of Vas Deferens
What causes male infertility in relation to testes?
- Testicular Maldescent
- Varicocele
- Dilatation of pampiniform plexus of veins
What causes male infertility in relation to hypospadias?
Urethral opening not in usual place
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