My Clinical Notes

• Couple are considered ‘subfertile’ if conception hasn’t occurred after 1year of unprotected sex
• May be primary meaning the female partner has never conceived
• Secondary indicating she has previously conceived, even if that pregnancy concluded with a miscarriage or abortion

Conditions for pregnancy

• An egg must be produced
• Adequate sperm must be released – the male factor probably contributes to 25% of cases
• Sperm must reach the egg
• The egg must implant

Disorders of ovulation

• Contributory cause in 30% of subfertile couples
• Detection of ovulation
  • Cervical mucus pre-ovulation is acellular and will ‘fern’ and form spinnbarkeit
  • Body temp drops 0.2 degrees pre-ovulation and rises 0.5 degrees in the luteal stage
• Investigations
  • Elevated levels of progesterone in the mid luteal phase (d21) are indicative of ovulation
  • Ultrasound can demonstrate changes in follicular growth
  • LH surge can be detected using over the counter predictor tests

Causes of anovulation

Polycystic Ovary Disease

• 2 out of 3 of the following criteria must be met
  • Anovulation/oligo-ovulation
  • Clinical/biochemical evidence of hyperandrogenism
  • Ovarian ultrasound features - >10 follicles in a 4-8mm diameter

Ovarian volume >10ml

• Those with polycystic ovary disease are at risk of developing polycystic ovary syndrome
• Clinical features of which are
  • None
  • Subfertility
  • Oligomenorrhoea/amenorrhoea
  • Hirsutism/acne
  • Obesity
  • Recurrent miscarriage (if there are increased LH levels)

Pathology

• Mainly genetic
• Insulin resistance, increased LH and adrenal and ovarian androgen production are involved in a breakdown of the normal feedback methods between the pituitary and the ovary
• 40-50% of women with PCOS develop diabetes

Treatment

• Clomifene – blocks oestrogen receptor in the hypothalamus to induce ovulation
• Gonadotrophins
• Metformin – insulin resistance
• Laproscopic ovarian diathermy
• Finasteride- reduces hirtuism
• Cyproterone acetate – acne

Side effects of ovulation induction

• Multiple pregnancy
• Ovarian hyperstimulation syndrome – results in large, painful follicles. In severe cases this can result in hypovolaemia, electrolyte imbalances, ascites and pulmonary oedema
• Ovarian carcinoma – conflicting evidence

Hypothalamic causes of anovulation

Hypothalamic hypogonadism

• Reduction inGnRH release
• Associated with anorexia nervosa, athletes and women under stress
• Kallmann’s syndrome occurs when GnRH secreting neurones fail to develop
• Exogenous gonadotrophins are required to induce ovulation

Pituitary causes of anovulation

Hyperprolactinaemia

• Excess prolactin production inhibits GnRH release
• Usually caused by a benign adenoma or hyperplasia of the pituitary cells
• Accounts for 10% of anovulatory women
• Can be associated with galactorrhoea or headaches and a bitemporal hemianopia if due to an enlarging tumour
• Treated with dopamine agonists – bromocriptine/cabergoline

Pituitary damage

• Reduces FSH and LH whilst production of GnRH levels are normal
• May be due to pituitary tumours or Sheehan’s syndrome

Other causes

• Hyper/hypo thyroidism
• Androgen secreting tumours

Male Subfertility

Normal semen analysis

• Volume >2ml
• Sperm count >20million/ml
• Progressive motility >50%
• Abnormal forms <30%

Descriptions of abnormal semen

• Azoospermia no sperm present
• Oligospermia <20million/ml
• Severe oligospermia <5million/ml
• Asthenozoospermia absent or low motility
• Teratozoospermia excess of abnormal forms

Causes

• Idiopathic
• Drug exposure
• Varicocoele
• Antisperm antibodies

Management

• Lifestyle advice
• Ligation of varicocoele
• Gonadotrophin treatment of pituitary disease
• Assisted conception techniques
• In vitro fertilisation
• Intracytoplasmic sperm injection
  

Disorders of fertilisation

• Sperm and eggs unable to meet in 30% of subfertile couples

Tubal Damage

• PID
  • Causes adhesions to form in and around fallopian tubes
  • Microsurgery can be used in mild disease
• Endometriosis
• Previous surgery – formation of adhesions

Cervical problems

• Anti-sperm antibodies which agglutinate sperm
• Infection of the vagina/cervix which prevents adequate mucus production
• Cone biopsy for CIN

Detection of problems with fertilisation

• Laproscopy and dye test
• Hysteroscopy
• Hysterosalpingogram

Assisted Conception

Intrauterine Insemination

• At the time of ovulation, washed sperm are injected into the cavity of the uterus
• Requires the fallopian tube to be patent

In vitro fertilisation

• Eggs collected under anaesthetic by aspirating follicles under ultrasound guidance
• Incubated with washed sperm
• Transferred into uterus 3-5 days later
• No more than 2 embryos are implanted
• Luteal phase support, progesterone or hCG is usually given until 12 weeks

Intracytoplasmic sperm injection

• Sperm are injected straight into the oocyte
• Allows use of poor quality sperm
• Sperm can be recovered directly from the testes or epidymis

Complications

• Superovulation
• Egg collection – haemorrhage and infection
• Pregnancy – multiple pregnancies, miscarriage, ectopic, perinatal mortality and morbidity

This entry was posted on Saturday, September 29th, 2007 at 4:27 pm and is filed under Gynaecology/Obstetrics. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.