Infertility Dafydd Ywain & Kayleigh Hansen
Terminology Epidemiology Aetiology Male infertility Female infertility Conclusion Content
Terminology Fecundability The probability of conceiving during a single monthly cycle In normally fertile couples it is 20-25% with a cumulative 85-90% chance of pregnancy within 12 months Infertility The inability to conceive after 12 months of appropriately times intercourse without contraception in women aged <35 or after 6 months in women aged >35 Primary infertility The couple have never achieved a pregnancy Secondary failure to conceive The couple have at least one previous conception
Epidemiology 10-15% of reproductive age married couples are infertile The prevalence of infertility has remained constant http://rollercoasterridetoparenthood.blogspot.co.uk/2013/04/i-am-face-of-infertility.html
Conditions for pregnancy 1. An egg must be produced 2. Adequate sperm must be released 3. The sperm must reach the egg 4. The fertilized egg (embryo) must implant http://www.tutorvista.com/content/biology/biologyii/reproduction/fertilisation.php http://www.bing.com/images/search?q=sperm+fertilisation&form=hdrsc2#vi ew=detail&id=d8aeb7b7a4f999f71c981d1337b2def59f13950b&selectedinde x=12
Aetiology Contributors to subfertility 4% 4% 25% 25% 21% Ovulatory problems Male problems Tubal problems Coital problems Cervical problems Unexplained 21%
Female Problems Disorders of Ovulation (30%) Hypothalamic dysfunction Pituitary dysfunction Ovarian dysfunction Tubal Problems (25%) Infection Endometriosis Previous Surgery Cervical problems (<5%) Anti-sperm antibodies Infection Cone Biopsy http://www.optionsforwomenphc.com/emergency-contraception/femalereproductive-system
Control of Ovulation: the Hypothalamic-pituitary-gonadal axis http://www.cakechooser.com/menstrual-cycle-hormones/
Detection of Ovulation Body temp tracking and cervical mucus analysis Serum Progesterone levels Elevated in mid-luteal phase Test on day 21 of regular 28 day cycle Urinary LH levels Used in OTC ovulatory predictor kits http://asanafoods.com/blog/maca-effects-on-thyroid-hrt-and-menstrual-periods/
Anovulation: Causes Hypothalamus: Hypothalamic Hypogonadism GnRH - LH/FSH - Oe 1 o : Kallman s Rx: Exogenous GnRH /Gonadotropins 2 o : Anorexia Nervosa, Exercise, Stress Rx: Lifestyle modification and body weight restoration Pituitary: 1. Hyperprolactaemia PRL - GnRH - LH/FSH - Oe a. Benign pituitary adenomas b. Psychotropic drugs Rx: Bromocriptine/Cabergoline 2. Pituitary damage LH/FSH - Oe. Normal GnRH a. Pressure from tumours b. Infarction following PPH (Sheehan s syndrome) http://activeroots.blogspot.c o.uk/2011/01/stop-runningmarathons-to-loseweight.html http://neurosurgery.ucla.edu/body.cfm?id=145 http://www.myvmc.com/health/drugs/
Anovulation: Causes cont. Ovarian: 1. Polycystic Ovary syndrome Other: Hypo / Hyperthyroidism 2. Premature Ovarian failure Loss of ovarian reserve early menopause Oe - GnRH - LH/FSH Rx. Donor oocyte required 3. Ovarian dysgenesis Turner s (45 XO) Androgen Insensitivity http://www.merckmanuals.coml 4. Luetinised unruptured follicle syndrome Follicle develops normally but fails to rupture and release egg. Usually able to conceive naturally (intermittent problem) http://www.nhs.uk/conditions/turners-syndrome/pages/introduction.aspx
PCOS PCO: 20% F - majority ovulate regularly PCOS: 5% F accounts for 80% of anovulatory subfertility LH and insulin resistance: ovarian androgen production disruption of folliculogenesis peripheral androgen production: Hirsuitsism Type II diabetes risk screening Symptom control: COCP / Metformin / Antiandrogens Inducing Ovulation: Clomifene / Gonadotropins Diagnostic criteria - 2 of: 1. PCO on USS 2. Irregular cycle (>35 days) 3. Hirsuitism: excess body hair, acne, serum testosterone http://www.rrc.com/info/pcos.php http://www.centerforhumanreprod.com/pcos.html
Tubal Problems Infection Chronic PID (Chlamydia 60%) adhesions, obstruction, hydrosalpinx / pyosalpinx 12% F infertile after single infection Laparoscopic adhesiolysis +/- salpingostomy or Salpingectomy Endometriosis 25% subfertile women but a proportion may be incidental Inflammation adhesion formation Laparoscopic ablation +/- adhesiolysis (not medical Rx) http://iahealth.net/pelvic-inflammatory-disease/ Previous Surgery inc. serialisation Laparoscopy and Dye Test: to determine tubal patency http://www.i-ampregnant.com/encyclopedia/pregnancy/endometriosis
Male Problems
Abnormal/Absent Sperm Idiopathic Oligospermia and asthenoozoospermia are common Sperm numbers and/or motility are low but not absent Drug exposure Alcohol, smoking, drugs (anabolic steroids) and exposure to industrial chemicals can impair fertility Varicocoele Varicosities of the pampiniform plexus Present in 25% of infertile men but 15% of all men http://www.bing.com/images/search?q=varicocele&qs=n&form=qbir&pq=v aricocele&sc=8-10&sp=- 1&sk=#view=detail&id=6FE17F0C643DE7D0DE07F10919DFE273F8362237&s electedindex=92
Abnormal/Absent Sperm Antisperm antiboides Present in 5% of infertile men Poor motility and clumping of the sperm are evident on semen analysis Other causes Infections (epididymitis) Mumps orchitis Testicular abnormalitis (Klinefelter s syndrome) Obstruction to delivery (absent vas deferens) Retrograde ejaculation (ejaculation into the bladder) Hypothalamic problems
Taking a History Past medical history Cystic fibrosis Epididymo-orchitis May cause epididymal obstruction Post pubertal mumps orchitis May cause testicular atrophy Chronic medical conditions (e.g. renal disease) May impair spermatogenesis Past surgical history Inguinal hernia repairs May lead to obstruction of the vas deferens Undescended testis Affects semen quality Testicular torsion Reduced fertility Bladder neck surgery including TURP May cause retrograde ejaculation http://www.bing.com/images/search?q=testicular+toprsion&qs=n&form=qbir pq=testicular+toprsion&sc=8-19&sp=- 1&sk=#view=detail&id=75F1B9A2A33F203AA9CB79FCE4505D4A7E495D9D&se ectedindex=5 http://www.bing.com/images/search?q=cystic+fibrosis+x+ray&qs=n&form=qbir &pq=cystic+fibrosis+x+ray&sc=0-16&sp=- 1&sk=#view=detail&id=9C6C669CB6525BAC965C5222AA2CBC778E2C3F34&sele ctedindex=7
Taking a History Drug history B Blockers may cause impotence A blockers may interfere with ejaculation Anabolic steroids, cannabis, cocaine, sulfasalazine, nitrofurantoin and tetracyclines Social history Smoking can impair the quality of the sperm Excessive alcohol reduces semen quality Occupational history Heavy metals, solvents and agricultural chemicals are associated with oligospermia http://www.bing.com/images/search?q=smoking+sperm+pack&qs=n&form=qbi R&pq=smoking+sperm+pack&sc=0-0&sp=- 1&sk=#view=detail&id=5AED4BB87B0FA57536AFACAC7921FE23FD31BB68&sel ectedindex=10
Semen analysis Normal semen analysis virtually excludes a male cause for subfertility Sample should be produced following 2-7 days abstinence Sample must be analysed within 1-2h of production Abnormal results must be repeated after 12 weeks Azoospermia No sperm present Oligospermia <15 million/ml Severe oligospermia <5 million/ml Asthenospermia Absent/low motility http://www.bing.com/images/search?q=normal+semen+analysis+report&qs =n&form=qbir&pq=normal+semen+analysis+report&sc=1-28&sp=- 1&sk=#view=detail&id=708376725A728B4C1BBAF2022246BF9B2129ED84& selectedindex=20
Examination Calculate BMI Secondary sexual characteristics Inadequate virilization could be due to abnormal karyoytpe Scars from inguinal hernia May suggest an obstructive problem Testicular size Measure using an orchidometer Palpate to check for presence of the vas deferens http://www.bing.com/images/search?q=klinefelters&qs=n&form=qbir&pq= klinefelters&sc=8-12&sp=- 1&sk=#view=detail&id=1B64005A0A99D4865FFCD4974600933936706280& selectedindex=1 http://www.bing.com/images/search?q=orchidometer&qs=n&form=q BIR&pq=orchidometer&sc=3-11&sp=- 1&sk=#view=detail&id=C5E64EBD9407A8CA8A3B09767650B2A2F0BC 83FF&selectedIndex=3
Management General advice Address lifestyle changes and drug advice Specific measures Varicocoele: Ligation does NOT significantly improve fertility and is not recommended Hypogonadotrophic hypogonadism: Treated with twice weekly subcutaneous injections of FSH and LH for 6-12 months Assisted conception techniques IUI in mild to moderate sperm dysfunction IVF in severe oligospermia ICSI in very severe oligospermia
Assisted Conception Over 1% babies born in the UK Intrauterine Insemination (IUI) In Vitro Fertilisation (IVF) Intracytoplasmic Sperm Injection (ICSI) Frozen Embryo Replacement (FER) Oocyte donation / Sperm donation Pre-implantation Genetic Diagnosis (PGD) Surrogacy
http://www.acfs2000.com/basic_services/intrauterine-insemination-iui.html Natural cycle or stimulated IUI Unexplained / Cervical / Sexual problems Requires patent tubes Cheaper but less successful than IVF (success 5-10% per stimulated cycle)
IVF 1. Follicular stimulation 2. Oocyte harvesting 3. Fertilisation and culture 4. Embryo transfer 5. Post-implantation progesterone http://www.kjivf.com/ivf-treatment-center-india.php Success rates 35% per stimulated cycle < 36 yrs; falling to 10% >40 yrs Requires sufficient ovarian reserve (AMH) Oocyte donation may be used if inadequate ovarian reserve Requires adequate sperm quality (or ICSI) http://www.ecoivf.com/treatment-options/icsi/
National Assembly for Wales Guidelines Female age <40 No biological / adopted children (either partner) BMI >19 and <30 (both partners) Infertility not due to elective sterilisation Smoking cessation Should not have had 3 previous IVF cycles (either partner) Subfertility demonstrated (> 2 yrs unprotected sex / failure of natural cycle insemination >5 times / fertility problem documented) Couples / Single parents eligible for 2 full cycles (one fresh + one frozen transfer per cycle) to be funded by the NHS
Conclusion Fertility is a complex issue, involving a couple Important to take a sensitive approach Feelings of inadequacy are common Guilt for pervious STI / Termination Counselling may be useful especially if underlying sexual dysfunction Treatment is not always successful: emotionally difficult to deal with strain on relationships common Support groups may help http://www.infertilitynetworkuk.com/ http://www.infertilitynetworkuk.com/support
References Impey, L & Child, T. Obstetrics and Gynaecology. 4 th Ed. 2012. Wiley- Blackwell NHS Choices: Information on Infertility. Available at: http://www.nhs.uk/conditions/infertility/pages/introduction.aspx Patient.co.uk: Information on fertility treatments. Available at: http://www.patient.co.uk/doctor/infertility-treatments National Assembly for Wales Guidelines for IVF. Available at: http://www.assemblywales.org/11-028.pdf Infertility Network UK website. Available at: http://www.infertilitynetworkuk.com/