When should investigations be offered for subfertility?
after 1 year of unsuccessful trying
What are the causes of sub fertility?
♣ Anovulation - 21% ♣ Male factor - 25% ♣ Tubal factor - 15-20% ♣ Unexplained - 28% ♣ Endometriosis - 6-8%
What are causes of anovulation?
→ Premature ovarian failure → Turner’s syndrome → Surgery → Chemotherapy → PCOS (accounts for 80% of anovulation) → XS weight loss or exercise → Hypopituitarism → Kallman’s syndrome
What should be taken from the Hx?
• Age and duration of subfertility
• Previous children?
• Menstrual Hx, regularity, pelvic pain, hx of STIs, previous surgery
• Smoking and alcohol reduces fertility
Male - undescended testes, mumps as an adult
What should be taken into account with the examination of subfertility?
- BMI - obesity has adverse effect on fertility
- Signs of endocrine disorder e.g. PCOS
- Pelvic pathology - endometriosis, fibroids
- Cervical smear, high vaginal and chlamydia swab
What investigations should be taken for sub fertility in primary care?
- Clap screening
- Baseline hormones - day 2-5 FSH and LH
- TSH, prolactin, testosterone and rubella status
- Mid-luteal progesterone level to confirm ovulation e.g. day 21 of cycle, >30nmol/L = ovulation
- Semen analysis - repeat in 3 m if abnormal after making lifestyle changes and starting multivits
What secondary care ix are given for subfertility?
- TVS - rule out adnexal masses, submucosal fibroids or endometrial polyps or PCOS
- HSG (Hysterosalpingogram)
− Using XR and contrast into the cervix to look at anatomy and tubal patency
− This ix can cause period like cramps and tubal spasm, giving false +ve
− Perform once clap swabs -ve and give azithromycin stat
Hysterosalpingo-contrast sonograph - Laparoscopy and dye test: gold standard for assessing tubal patency
What is involved in laparoscopy and dye test?
− Methylene blue dye injected through the cervix and tubes visualised w laparoscope
− Pelvic pathology can be treated at the same time
What is lifestyle management of subfertility?
→ Direct at the cause → Lose weight → Stop smoking → smoking → Exercise → Folic acid in the woman → Regular intercourse every 2-3 days
What are the different treatments involving ovulation induction?
Clomifene Laparoscopic ovarian drilling gonadotrophns Metformin Surgical techniques - Catheterisation or hysteroscopic cannulation Gonadatrophins Metform
When are gonadatrophins indicated?
Clomifene resistant PCOS or low oestrogen w normal FSH
What are the options in surgery for subfertility and what are they indicated for?
Catheterisation/cannulation to proximally blocked tubes Treating endometriosis (ablation, excision, coagulative techniques) Hysteroscopic adhesiolysis for intrauterine adhesions
When is IVF indicated?
- Tubal disease
- Male infertility
- Endometriosis
- Anovulation not responding to clomifene
- Subfertility due to age
- Unexplained infertility >2yrs
In who does IVF have a poorer response?
∞ Age ∞ duration of infertility ∞ Prev. Unsuccessful IVF ∞ Smoking ∞ High BMI ∞ Low anti-Mullerian hormone
What should be done to a couple before IVF?
screen them for HIV, hep B and C
Explain the process of IVF
- Stimulate ovaries
- Collect ova by TV aspiration under TVS guidance
- Fertilise ova
- 3-5 days later, return 1-2 embryos under US guidance to uterus
- Give luteal support in the form of progestagens
- Pregnancy test 2 weeks later
Where does spermatogenesis occur?
seminiferous tubules
What roles do FSH and LH and testosterone play in spermatogenesis?
FSH and LH important for starting it at puberty
LH stimulates Leydig cells to produce testosterone
FSH and testosterone stimulate Sertoli cells to produce essential substances for metabolic support of germ cells and spermatogenesis
How much of the volume of ejaculate does seminal fluid make up?
90%
Why is seminal fluid alkaline?
to buffer vaginal acidity
What is the % of normal form in sperm?
> 4
What is the normal total motility percentage in sperm
40
What is the normal progressive motility in sperm
> 40%
What is the normal conc of sperm
> 1.5x106ml
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Adenomyosis11
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Amenorrhoea28
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Benign Ovarian Tumours30
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Cervical screening and CIN30
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Cervical problems18
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Dyspareunia8
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Endometriosis17
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Female Genital Mutilation8
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Fibroids18
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Endometrial cancer11
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Genital abnormalities6
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Gestational Trophoblastic Disease10
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Pelvic Inflammatory Disease15
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Prolapse28
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Subfertility35
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Cervical cancer9
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Vulval cancer5
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Ovarian Cancer14
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Vaginal Cancer7
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Menopause21
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Menorrhagia12
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Ovarian Hyperstimulation Syndrome13
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Polycystic Ovary Syndrome11
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Premature Ovarian Insufficiency6
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Premenstrual Syndrome8
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Vaginal infections36
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Vulval disorders29
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Pelvic pain16
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Ectopic pregnancy13
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Miscarriage15
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Breast Cancer32
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Benign Breast Lumps27
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Mastitis10
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Paget's disease5
