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Subfertility and Assisted Reproduction - Overview and Investigation -…
Subfertility and Assisted Reproduction - Overview and Investigation
Overview
Definition
A disease of the reproductive system defined by the fialure to achieve a aclinical pregnancy after 12 months or more of regular unprotected intercourse
Epidemiology
1 in 6 couples subfertile
1st year - 80% conceive
Under 40
No contraception
Intercourse every 2-3 days
2nd year 10% conceive
10% don't
90% concieve within 2 years
Risk Factors
Female
Age over 35
Irregular periods / anovulation
Endometriosis
PCOS
H xof STI
Hx of pelvic surgery
Ovarian cyst
Fibroids
Oophorectomy
Hx ruptured appendix, bowel surgery (IBD)
Obesity
Fhx early menopause
Cancer treatment
Male
Age >45
Hx testicular surgery
Torsion
Ochidoexy
Hx testicular injury
Hx STI
Cancer treatment
Previious testicular infections
NICE Guidlines
A woman of reproductive age who has not concieved after 1 yr of unprotected vaginal sexual intercourse
in the absence of a known cause of infertility
should be offered further clinical assessment and investigation along with her partner
Offer an earlier referral for specialist consultation to discuss the options for attempting conception, further assessment and appropriate treatment where:
the woman is aged 36 years or over
there is a known clinical cause of infertility or a history of predisposing factors for infertility.
Classification
Primary
No previous pregnancy
Secondary
Previous pregnancies
Psychological Impact
Reassurance
Councelling
Education
Support groups
Female Age and Fertility
↓ Oocyte quality
↑ Embryo aneuploidy
↓ Pregnancy
↑ Miscarriage
Female Causes
Ovulation Disorders 25%
PCOS
Hypothalamic
Premature ovarian insufficiency
Tubal factors 20%
Endometriosis
PID
Previous surgery
Unexplained 25%
Uterine 10%
Polyps
Fibroids
Adhesions
Anomalies / septum
Cervical
LLETZ - removal of abnormal cells
Cone bx / Trachelectomy
Male Causes 30%
Pychosexual
Erectile dysfunction
Aquired
Testicular injury
Testicular surgery
Infection
Mumps
Epididymoorchitis
Varicocele
Drugs
Congenital / Genetic
XXY
Cryptorochidism
Androgen insensitivity
Y chromosome microdeletions
Endocrine / Systemic
Kallman's syndrome
Pituitary tumours / infiltration
Head trauma
Severe systemic illness
Obesity
Nutritional deficiency
History / Exam
Female
Obs
Primary vs secondary infertility
Previous pratners
Miscarriages / ectopics
Previous interventions / procedures
LSCS
ERPC / STOP
Gynae
Cycle
Regularity, freqency ,duration, volume
SI and timing , signs of ovulation
Pain, dysmenorrheoa, dyspareunia → endometriosis
Acne, hirsuitism, olig/amenorrhoea → PCOS
Cervical smears
PMhx / PShx
Need for pregnancy councelling
Previous abdominal / pelvic surgery
Meds
Medication review - teratogenicity
Folic acid / Vit D
Shx
Smoking
Exercise
Enough / excessive
Weight loss / gain
Male
Paternity hx
Previous children / pregnancies
PMhs
Mumps
Systemic illnessses
Chemo / radiation
PShx
Cryptorchidism ( later surgery ∝ higher impact on sperm)
Hernias
Varicocele
Meds
Corticosteroids
Cyctotoxic chemotherapy
Sexual / Developmental hx
Sexual development, testicualr development
Hair growth . shaving frequency
Libido
Shx
Smoking
Drugs - Marijuana, Anablic steroids
Alcohol
Work - prolonged sitting
Exercise
Examination
Guided by hx eg androgen insufficiency
Hair pattern
Testicular size
Hernias
Varicocele
Lumps / cysts / massess
Investigations - Female
Ultrasound
Uterus
Endometrial thickness
Endometrial polyp
Fibroids
Type 0-6
Uterine cavity shape
Type 0,1 more likely to effect fertility
Ovaries
Ovarian cysts
Endometriomata
Signs of ovulation
Ovarian reserve - antral follicle count
Bloods
Hormones
Indications
If suspected anoluvation
Timing
Early follicular phase
Hormones
FSH
LH
Oestradiol
Prolactin
Testosterone
SHBG
Progesterone - Mid luteal phase
AMH - test of ovarian reserve (quantity not quality)
TFTs - thyroid dysfunction may impact ovulation
Signs of Ovulation
Mucous
Pain - Mittleschmerz
Raise in temp
Regular cycle
Ovarian Reserve Testing
Antral Follicle Count
Number of 2-9mm follicles
TIming
In early follicular phase
Day 2-5
AMH
Anti mullerian Hormone
Polypeptide of TGF-β Family
Solely secreted by granulosa cells of the preantral and small antral ovarian follicles
Serum levels correclate with Antral Follicle Count (AFC)
Caveate
Not a test of fertiity
Not a test of egg quality
Use: • help tell time left to conceive/ • help in predicting response to ART
Tubal Patency Testing
Risk factors
Previous surgery
RPevious ectopic pregnancy
Known / suspected endometriosis
hx PID
Hysterosalpingogram (HSG)
HyCoSy (Hystero salpingo contrast sonography)
Laparoscopy + Dye Test + Hysteroscopy
Previously gold standard 🥇
Invasive
Use
High risk for tubal pathology
Suspected endometriosis
Abnormality on USS / HSG / HyCoSy
Opportunistic - getting lap anyway
Sign of patency
Fill and spill
Others
HIV . Hep b / Hep C
Rubella
Cervical Smear
Investigations - Male
Semen Analysis
WHO Values
Sperm volume
pH 7.2+
Sperm concentration
15 million / ml
Total sperm number
Total motility
- 40% moving and 32% progressive moving
Vitality
Sperm
morphology
4% or more normal
If abnormal
Lifestyle modication
Repeat 3 months
Hormonal Profile
Indication
Low sperm count Under 10 on 2 occasions
Under 5 one occasion
Hormones
FSH
LH
Testosterone
Ddx
Pituitary hypogonadism
Testicular failure
Hypothalamic hypogonadism
Genetic Testing
Y chromosome microdeletions
Karytyping
Cystic fibrosis testing
Testicular USS +
Urology referral
Massess
Varicocele
Epididymal cyst
General Advice
Female
Alcohol
1-2 drinks once/ teice per week
Reduce
Smoking
Impact on pregnancy
Some evidence of impact on ovarian reserve
Caffeine
Limited evidence
Consider in line with pregnancy guidlines
Diet
Limmited evidence
Halthy , balanced
Exercise
Limit vigorous exercis (3 x / week)
Weight
BMI >30 more likely to take longer to conceive
BMI <19 - increasing weight improve chances of conceiving
Supplements
Folic acid
Vit D
Male
Drug use
Alcohol
Smoking
Recreational drugs
Anabolic steroids
Diet
Exercise
Moderate exercise god
Weight
BMI > 30 likely reduced fertility
Excessive heat effects sperm quality
No tight underwear
Occupation
Saunas
Supplements
Zinc
Vit E
Vit C
Limited evidence
Timing Sexual Intercourse
Every 2-3 days
Educate regarding fertile window
Ovulation testing kits - not needed really
