FERTILITY
Important facts:
• 85% will conceive within a year of regular UPSI.
• 1 in 6 couples will struggle to conceive naturally.
• Investigation and referral for infertility –-> couples without success for 12 months or 6 months (if women > 35yo)
• Oocytes (oogonia) reach MAX numbers at 20 wks GA ® NO NEW GERM CELL PRODUCTION IN THAT WOMAN’S LIFETIME EVER
• Aneuploidies arise within the oocytes over time and more frequently with ↑↑ maternal age (as oocyte left longer in prophase stage) ® = ↑↑↑risk of
(meiotic) non-disjunction + mal-segregation of homologous chromosomes (M1) or sister chromatids (M2)
FEMALE INFERTILITY
Female ONLY SUB-fertility Ix MANAGEMENT
Pre-ovarian cause Primary care screen Lifestyle
Ø Stop smoking, alcohol
HYPOgonadotrophic HYPOgonadism • BMI - low (anovulation), high
Ø Reduce weight (diet, PA)
(PCOS)
• pituitary disease, Ø REDUCE STRESS
• C+G screening Ø Avoid timed intercourse
• Kallman’s,
• Serology = Hep B/C, HIV, Syphilis, Ø Folic Acid, iodine supplementation
• idiopathic,
Rubella, Varicella
• anabolic steroids, Specific Mx
• functional e.g. weight loss/XS • Weight loss
Hormonal screen:
exercise • Clomifene (stimulate ovulation)
• FSH - high (low ovarian reserve – Anovulation • Ovarian drilling during hysteroscopy – punch holes
pituitary compensation to stimulate in ovaries w/ diathermy or laser
Ovulatory failure (30%): follicular development) • Metformin (PCOS)
• HYPERgonadotrophic HYPOgonadism • LH – high (?PCOS) • Tubal cannulation during hysterosalpingogram
(premature ovarian failure) • Progesterone (7 days post- Tubal • Laparoscopic removal of adhesions /
• Hyperprolactinaemia ovulation) = rise factors endometriosis
• ↓Leptin and estrogen = central • IVF
• PCOS
hypogonadism Uterine Excise polyps, adhesiolysis and correct abnormal
• Menopause factors structures
• AMH (ovarian reserve)
• Cushing’s
• TFT IN-VITRO FERTILISAcTION
• Hypo/hyperthyroidism
• ↑ PrL - ?galactorrhea, amenorrhea Fertilise egg with sperm in lab (25-30% success rate)
Ø Suppress natural menstural cycle (daily SC injections of GnRH
Post-ovarian (Passage) problems: (30%) agonist or antagonists)
Imaging for anatomical issues Ø Ovarian stimulation (IM HCG)
• Tubal damage (previous STI)
• Baseline Pelvic USS – pathology Ø Oocyte collection (under sedation via TVUS)
• PID and antral follicle count o A/E = pain, bleed, damage to adjacent bladder, PID
• Endometriosis • HyCoSy – test for tubal patency / Ø Insemination w/ sperm
obstruction Ø Intracytoplasmic sperm injection (ICSI)
• Congenital malformation
Ø Embryo culture – UNTIL blastocyst stage
• Polyps / fibroids (sub-mucosal ― Check for negative C+G
Ø Embryo transfer
uterus) before HyCoSy
• Mullerian agenesis (15%) Main complications of IVF
Ø Failure
Ø Ectopic
Ø Multiple pregnancies
Ø Ovarian hyperstimulation syndrome (OHSS)
Note: Ovarian hyperstimulation syndrome (OHSS)
PP Sx Ix Mx
Ø Assoc. w/ use of HCG stimulation Ø Within 7-10 days of HCG • Serum Estrogen +++ Use lower HCG, GnRH dosages if risk factors
Ø ↑HCG = ↑VEGF = ↑vasc. Permeability DEHYDRATION SIGNS (diarrhoea, • Pelvic USS present
Ø Oedema, ascites and hypovol.(↑HCT) hypoTN, N/V) o ascites ABCDE
Ø RAAS activation = ↑Renin • Mild = abdo pain _ bloating o higher # & size of Ø PO fluids or IV colloids
Risk factors: • Mod = ascites (seen on USS) follicles Ø Monitor in.out (UO)
Ø Young, low BMI women • Severe = oliguria, hyperK, high Ø 40mg prophylactic clexane
Ø PCOS, high AMH, follicle counts HCT and hypoalbumin Ø Paracentesis (if needed)
• Critical = anuria, VTE, ARDs Refer to
Ø Outpatients = mild/mod
Ø ICU = severe
MALE INFERTILITY
Male ONLY (50%) SUB-fertility Ix Management
Pre-testicular cause Hormonal analysis Rx underlying cause
• Hypogonadotrophic hypogonadism Ø LH, FSH, TT levels Ø Surgical sperm retrieval (if obstruction )
(e.g. pituitary disease, Kallman’s, idiopathic, anabolic Ø Trans-rectal USS /MRI Ø Surgical correction (obstructed vas deferens)
steroids, functional e.g. weight loss/XS exercise) Ø Vasography –inject contrast into vas deferens Ø Intra-uterine insemination (selectively obtain the
check for obstruction best sperm and inject into uterus)
Testicular cause (spermatogenesis issue): Ø Testicular biopsy Ø Intracytoplasmic sperm injection (ICSI) (injection
• Hypergonadotrophic hypogonadism sperm directly into cytoplasm of an egg)
(Klinefelter – testicular dysgenesis, gonadal damage Semen Analysis (MASTURATION) Ø Sperm donor
– chemo, RT, trauma) • 2-day abstinence
• Anti-sperm antibodies • Avoid factors affecting quality (see right) Advise factors affecting sperm quality
• Analysis within 30-60mins Ø Hot baths
Passage (Post-testicular) problems: Ø Tight underwear
• Blocked vas deferens / ejaculatory duct Test SPERM for Ø Smoking
• Absent vas deferens (CF. CAH) • Concentration (< 15 mill) Ø Alcohol
• Retrograde ejaculation (?TURP) • Motility (< 40%) Ø Obesity
• Epididymal scarring (post-C+G infection) • Morphology (<4% normal) Ø Caffeine
Important facts:
• 85% will conceive within a year of regular UPSI.
• 1 in 6 couples will struggle to conceive naturally.
• Investigation and referral for infertility –-> couples without success for 12 months or 6 months (if women > 35yo)
• Oocytes (oogonia) reach MAX numbers at 20 wks GA ® NO NEW GERM CELL PRODUCTION IN THAT WOMAN’S LIFETIME EVER
• Aneuploidies arise within the oocytes over time and more frequently with ↑↑ maternal age (as oocyte left longer in prophase stage) ® = ↑↑↑risk of
(meiotic) non-disjunction + mal-segregation of homologous chromosomes (M1) or sister chromatids (M2)
FEMALE INFERTILITY
Female ONLY SUB-fertility Ix MANAGEMENT
Pre-ovarian cause Primary care screen Lifestyle
Ø Stop smoking, alcohol
HYPOgonadotrophic HYPOgonadism • BMI - low (anovulation), high
Ø Reduce weight (diet, PA)
(PCOS)
• pituitary disease, Ø REDUCE STRESS
• C+G screening Ø Avoid timed intercourse
• Kallman’s,
• Serology = Hep B/C, HIV, Syphilis, Ø Folic Acid, iodine supplementation
• idiopathic,
Rubella, Varicella
• anabolic steroids, Specific Mx
• functional e.g. weight loss/XS • Weight loss
Hormonal screen:
exercise • Clomifene (stimulate ovulation)
• FSH - high (low ovarian reserve – Anovulation • Ovarian drilling during hysteroscopy – punch holes
pituitary compensation to stimulate in ovaries w/ diathermy or laser
Ovulatory failure (30%): follicular development) • Metformin (PCOS)
• HYPERgonadotrophic HYPOgonadism • LH – high (?PCOS) • Tubal cannulation during hysterosalpingogram
(premature ovarian failure) • Progesterone (7 days post- Tubal • Laparoscopic removal of adhesions /
• Hyperprolactinaemia ovulation) = rise factors endometriosis
• ↓Leptin and estrogen = central • IVF
• PCOS
hypogonadism Uterine Excise polyps, adhesiolysis and correct abnormal
• Menopause factors structures
• AMH (ovarian reserve)
• Cushing’s
• TFT IN-VITRO FERTILISAcTION
• Hypo/hyperthyroidism
• ↑ PrL - ?galactorrhea, amenorrhea Fertilise egg with sperm in lab (25-30% success rate)
Ø Suppress natural menstural cycle (daily SC injections of GnRH
Post-ovarian (Passage) problems: (30%) agonist or antagonists)
Imaging for anatomical issues Ø Ovarian stimulation (IM HCG)
• Tubal damage (previous STI)
• Baseline Pelvic USS – pathology Ø Oocyte collection (under sedation via TVUS)
• PID and antral follicle count o A/E = pain, bleed, damage to adjacent bladder, PID
• Endometriosis • HyCoSy – test for tubal patency / Ø Insemination w/ sperm
obstruction Ø Intracytoplasmic sperm injection (ICSI)
• Congenital malformation
Ø Embryo culture – UNTIL blastocyst stage
• Polyps / fibroids (sub-mucosal ― Check for negative C+G
Ø Embryo transfer
uterus) before HyCoSy
• Mullerian agenesis (15%) Main complications of IVF
Ø Failure
Ø Ectopic
Ø Multiple pregnancies
Ø Ovarian hyperstimulation syndrome (OHSS)
Note: Ovarian hyperstimulation syndrome (OHSS)
PP Sx Ix Mx
Ø Assoc. w/ use of HCG stimulation Ø Within 7-10 days of HCG • Serum Estrogen +++ Use lower HCG, GnRH dosages if risk factors
Ø ↑HCG = ↑VEGF = ↑vasc. Permeability DEHYDRATION SIGNS (diarrhoea, • Pelvic USS present
Ø Oedema, ascites and hypovol.(↑HCT) hypoTN, N/V) o ascites ABCDE
Ø RAAS activation = ↑Renin • Mild = abdo pain _ bloating o higher # & size of Ø PO fluids or IV colloids
Risk factors: • Mod = ascites (seen on USS) follicles Ø Monitor in.out (UO)
Ø Young, low BMI women • Severe = oliguria, hyperK, high Ø 40mg prophylactic clexane
Ø PCOS, high AMH, follicle counts HCT and hypoalbumin Ø Paracentesis (if needed)
• Critical = anuria, VTE, ARDs Refer to
Ø Outpatients = mild/mod
Ø ICU = severe
MALE INFERTILITY
Male ONLY (50%) SUB-fertility Ix Management
Pre-testicular cause Hormonal analysis Rx underlying cause
• Hypogonadotrophic hypogonadism Ø LH, FSH, TT levels Ø Surgical sperm retrieval (if obstruction )
(e.g. pituitary disease, Kallman’s, idiopathic, anabolic Ø Trans-rectal USS /MRI Ø Surgical correction (obstructed vas deferens)
steroids, functional e.g. weight loss/XS exercise) Ø Vasography –inject contrast into vas deferens Ø Intra-uterine insemination (selectively obtain the
check for obstruction best sperm and inject into uterus)
Testicular cause (spermatogenesis issue): Ø Testicular biopsy Ø Intracytoplasmic sperm injection (ICSI) (injection
• Hypergonadotrophic hypogonadism sperm directly into cytoplasm of an egg)
(Klinefelter – testicular dysgenesis, gonadal damage Semen Analysis (MASTURATION) Ø Sperm donor
– chemo, RT, trauma) • 2-day abstinence
• Anti-sperm antibodies • Avoid factors affecting quality (see right) Advise factors affecting sperm quality
• Analysis within 30-60mins Ø Hot baths
Passage (Post-testicular) problems: Ø Tight underwear
• Blocked vas deferens / ejaculatory duct Test SPERM for Ø Smoking
• Absent vas deferens (CF. CAH) • Concentration (< 15 mill) Ø Alcohol
• Retrograde ejaculation (?TURP) • Motility (< 40%) Ø Obesity
• Epididymal scarring (post-C+G infection) • Morphology (<4% normal) Ø Caffeine
