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Female subfertility (Aetiology (Iatrogenic Pituitary: brain surgery …
Female subfertility
Aetiology
Iatrogenic
Pituitary: brain surgery
Ovaries/tubes/uterus: surgery, chemo, RT
Trauma
Pituitary: head trauma
Ovaries/tubes/uterus: pelvic trauma
Neoplastic
Pituitary: prolactinoma (hyperprolactinemia)
Uterus/tubes: tumour, endometriosis, adenomyosis
Uterus: uterine cancer, fibroids
Endocrine
Pituitary: hypopituitarism
Ovaries: PCOS, premature ovarian failure
Congenital
Pituitary/hypo: Kallman syndrome
Ovaries: Turner syndrome
Tubes: tubular malformation
Uterus: uterine malformation
Infection
Pituitary: meningoencephalitis
Tubes: PID, salpignitis
Functional
Weight loss/exercise
Anorexia nervosa
Epidemiology
Common
1/6 couples seek help
85% pregnancy in 1y UPS1, >90% by 2y
Commonest causes are ovulatory disorders,
then tubal damage, then male infertility
Definition
Subfertility
Reduced fertility in a female of reproductive age,
with prolonged duration of no conception
Primary infertility
Infertility in a patient who has never concieved
(failure to conceive 1-2y reg UPSI every 2-3d)
Secondary infertility
Infertility in a patient who has previously concieved
(failure to conceive 1-2y reg UPSI every 2-3d)
Diagnosis
Investigations
Bloods
FBC, U+E, LFT, TFTs (thyroid disease)
Mid luteal progesterone (7d pre menses, to confirm ovulation)
Hormones (FSH/LH, PRL, testosterone, HMBG)
Rubella status
BBV screen (HIV, HBV, HCV, syphilis)
Imaging
Laparoscopy and dye (tubal patency by laparoscopy - gold standard)
Hysterosalpingography (tubal patency by hysteroscopy)
Hysterosalpingo-contrast-sonograph (USS plus contrast medium)
Bedside
Height, weight (BMI)
Obs (BP, HR, RR, sats, temp)
Swabs
STI screen (CT, NG, etc.)
Cervical smear
Examination
General
BMI, hyperandrogenism (acne, hirsuitism, alopecia),
thyroid (hypo/hyper), acanthosis nigricans (PCOS),
visual field defect (prolactinoma)
Pelvic
Masses/fibroids, endometriosis
Speculum
Endometriosis, cancer, infection,
vaginismus
History
POH
Gravity/parity, ectopics/miscarrages/live,
conception method, delivery,
gestation, weight, complications
PMH/PSH
Known medical conditions
Rubella vaccination status
Abdo/pelvic surgery
PGH
Known conditions
Menses (LMP, cycle, bleeds, pain)
Contraception, STIs, smears
DH
Any CI in pregnancy
Folic acid
Allergies
PC/HPC
Duration of subfertility, coital frequency
Previous children (self and partner),
systemic symptoms (acne, hirsuitism, galactorrhoea)
FH
Gynae disorders
Fertility problems
Cancers
SH
Living arrangements,
occupation, smoking, alcohol,
exercise, diet, social support
Management
Conservative
Lifestyle modification
Weight loss, diet and exercise
Smoking/alcohol/drug cessation
Folic acid
Investigations/referral
Unable to conceive after 1y of regular UPSI, or those less likely to conceive (>35y, known fertility problems, anovulatory cycles,
severe endometriosis, prev PID, malignancy)
Information and advice
Information on regular USPI throughout cycle,
particularly around ovulation
Counselling (Offer before and after treatment)
Rubella status and cervical screening
Medical
Ovulation inducation
Indication: PCOS
E.g. antioestrogens (clomifine), GnRH,
ovarian diathermy, insulin sensitisers (metformin)
Assisted reproductive
techniques (ART)
In-vitro fertilisation (IVF)
Sperm nucleus injected into oocyte
Blastocyst implanted into uterus
Oocyte donation
If oocytes not viable
Intrauterine insemination (IUI)
MOA: sperm injected directly into uterus
Surgical
Tubal surgery
Indication: tubal patency defect
MOA: microsurgery, adhesiolysis
Endometriosis surgery
Indication: endometriosis
MOA: laser/diathermy/excision
Pathophysiology
Anovulation
Hypogonadotrophic hypogonadism (10%)
Low GnRH thus low oestrogen
Hypo/pituitary failure
E.g. low BMI, Kallman's syndrome
Normogonadotrophic normogonadism (85%)
HPG axis intact, other features interfering
PCOS*, hyperprolactinemia
Hypergonadotrophic hypogonadism (5%)
Ovarian failure, hypo/pit hypersecrete to try
and compensate
E.g. Turner's syndrome, premature menopause
Structural
Ovaries
Uterus
Fallopian tubes
Clinical
presentation
No conception after
regular UPSI (2-3/wk) for 1-2y
Complications
Psychological
Stress, anxiety, depression