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Infertility

Infertility. Epidemiology Overview of fertility treatments. Infertility Overview. Epidemiology Natural conception Incidence Causes Investigation When Which tests. Key steps. Infertility - incidence. Incidence population based studies 24 months unprotected intercourse 1:6 overall

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Infertility

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  1. Infertility • Epidemiology • Overview of fertility treatments

  2. Infertility Overview • Epidemiology • Natural conception • Incidence • Causes • Investigation • When • Which tests

  3. Key steps

  4. Infertility - incidence • Incidence • population based studies • 24 months unprotected intercourse • 1:6 overall • Subfertility • Azoospermia (No sperm) • ovarian failure (No oocytes) • extensive tubal damage (Gametes cannot meet)

  5. Cumulative conception • Normal couples prospect of conception • 33% first month • 20-25% thereafter • 84% conceive by 1 year • 92% by 2 years

  6. Cause Frequency (%) Sperm dysfunction 30 Ovulation failure 25 Tubal infective damage 20 Unexplained 25 Endometriosis 5 Causes of infertility - diagnosis

  7. Infertility investigations - general advice • Check Rubella immunity (female) • Smoking (both) • Alcohol • Folic acid (female) • 0.4mg/d (reduces risk of spina bifida) • Weight (female) • BMI <30 • Kg/m2

  8. Infertility investigations - primary care • Develop local protocols • evidence based • Male • SFA x 2 • Female • midluteal progesterone • >30nmol/l

  9. Infertility investigations - lack of evidence • Not recommended routinely • Thyroid function • Prolactin • PCT/Sperm function tests • Endometrial biopsy or scan • Hysteroscopy

  10. When to refer early from primary care • Female factors • age > 35 yrs (biological clock) • Oligo/amenorrhoea • Previous pelvic surgery • PID/STD

  11. Seminal Fluid Analysis

  12. Sperm dysfunction • History / Examination • genitourinary surgery • undescended testis • mumps • Investigation • SFA • Azoospermia (check karotype) • Spontaneous conception • possible • 20% over 2 yrs • ICSI • 30%/cycle

  13. Ovulation • Physiological indicators of ovulation • Cervical mucus thins and increases • mid cycle pain (mittleschmertz) • Rise in basal body temperature • History suggestive of anovulation • infrequent / absent periods • >35 days apart • Mid luteal progesterone (<30mmol/l) 0 28 Day 21

  14. Failure of Ovulation • Anovulation • PolyCystic Ovarian Syndrome (PCOS) • Hyperprolactinemia • drugs • stress • pituitary tumor • Premature ovarian failure • 1% <40 yrs • 0.1% <30 yrs • Hypothalamic • Low GnRH drive

  15. Anovulation – management • PCOS • Clomifene • Metformin • FSH injections • Ovarian drilling • Hyperprolactinaemia • dopamine agonist (bromocriptine) • inhibits prolactin secretion • Premature ovarian failure • IVF donated oocytes • Hypothalamic causes • GnRH pump

  16. Tubal infective damage • Aetiology • Chlamydia trachomatis commonest • Silent carriage • Age <25 yr incidence increasing • TOP (7.5%) • 20-24yr (11.5%) • History • none • Pelvic Inflammatory Disease (PID) • infective complications following pregnancy • Diagnosis • Hystero-SalpingoGram (HSG) or Hycosys (screen) • laparoscopy

  17. Laparoscopy

  18. Tubal infertility - hydrosalpinx Offer salpingectomy if hydrosalpinx present (NICE)

  19. Tubal infective damage - management • Tubal surgery • major operation • limited success (20%) • ectopic pregnancy • Removal of tube • Potentially serious • IVF • expensive • complications • success rates depend on female age (30%)

  20. Cumulative conception in unexplained infertility

  21. Unexplained infertility - management • Wait • <3 years • reasonable prospect of conception • >3 years • IVF observe fertilisation occurring • IUI (intrauterine insemination) • Female age important

  22. Endometriosis • What is it ? • Endometrial cells at sites outwith the uterus • Ovary • Pelvis • Bowel/bladder • Lungs • Aetiology • ? retrograde menses • Familial association • Embolisation • Immunological

  23. Endometriosis • History • pelvic pain • Dysmenorrhoea • deep dyspareunia • Diagnosis • Laparoscopy • Why does it reduce fertility ? • ? Sperm function • ? Tubal motility • ? Oocyte quality

  24. Endometriosis - management • Laser or diathermy • improves conception rates • If pelvis anatomically distorted • IVF • laser to ovarian cysts

  25. Intrauterine insemination • Indications • Unexplained • Mild male factor • 2y infertility • Minor endometriosis • Tubal patency • Natural cycle • NICE guidance 6 unstimulated cycles • Stimulated cycle • Clomifene • FSH injections • Multiple pregnancy

  26. Indications for IVF/ICSI • IVF • Tubal • Prolonged unexplained • Severe endometriosis • Unexplained failure of ovulation induction • ICSI • Severe male factor • Failed ferilisation with IVF

  27. In vitro fertilisation (IVF) • Pituitary densitisation (GnRHa nasal spray) • Stops ovulation • Ovarian hyperstimulation (daily FSH injections) • Multiple follicles and eggs • Egg retrieval • Sedation TVUSS • Embryo transfer • Max 2 embryos (UK) • Luteal support • Progesterone pessaries • Issues • Welfare of the Child • Multiple pregnancy rates • Success rates • NHS funding • 3 cycles • Age 23-39 • criteria

  28. IVF Stimulation cycle - overview Menses Long GnRHa hCG Daily FSH injections Luteal support Cycle day 21 0 12 OR ET

  29. Risks in ART cycle • Poor ovarian response • Ovarian hyperstimulation syndrome • iatrogenic • PCOS • pregnancy • Multiple pregnancy • move to elective single embryo transfer

  30. Impact of female age and basal FSH on IVF livebirth rate(Akande et al 2002) Proportion of all pregnancies to women >35 years

  31. Can ART (IVF) compensate for the natural decline in fertility with age?Leridon 2004 • Computer Model of Reproduction • Combined • themonthly probabilities of conceiving • the risk of miscarriage • probability of becoming age-dependently permanentlysterile • Delay 30 to 35 years • IVF • Makes up for 50% of age related losses • Delay 35 to 40 years • Makes up for <30% • More precise information required about risks of postponing childbirth

  32. Infertility investigations - summary • Common condition (1:6) • Sperm dysfunction • SFA • Anovulation • history • midluteal progesterone • Tubal • HSG Hycosys or laparoscopy • Endometriosis • laparoscopy • Unexplained • all of above are normal

  33. Infertility treatment - summary • Sperm dysfunction • Mild IUI • Severe ICSI • Anovulation • PCOS • Clomifene • Metformin • FSH injections or Ovarian diathermy • Hyperprolactinaemia • Bromocriptine/cabergoline • Ovarian failure • IVF Donor eggs • Tubal • Surgery (mild) • IVF • Endometriosis • ablation improves • IUI or IVF • Unexplained • Wait IUI IVF

  34. www.rcog.org.uk • Student & junior doctor section • Careers • Advice on applying for Obstetrics & Gynaecology

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