Treatment of female infertility

Question 1

What is recommended alcohol intake for women undergoing IVF/trying to get pregnant

Answer 1

no more than 3-4 units of alcohol per week

1-2 units 2 x per week

Question 2

How long should folic acid be taken prior to pregnancy

Answer 2

before conception and up to 12 weeks of pregnancy to reduce chance of neural tube defect
0.4mg per day (women on antiepileptic should take 5mg per day)

Question 3

Describe treatment of PCOS

Answer 3

1. lifestyle factors, reduce BMI to less than 30
2. Clomiphene citrate+/- metformin
3. Laproscopic ovarian drilling, gonadotrophin therapy
4. Assisted conception

Question 4

How does clomiphene work

Answer 4

it is an anti oestrogen
blocks oestrogen feedback form ovaries to pituitary and hypothalamus thus ‘tricking’ pituitary into producing more FSH which may promote more sufficient follicle development

Question 5

How is clomiphene taken

Answer 5

as a tablet initial dose of 50mg onc daily for 5 days from day 2 of menstrual cycle

Question 6

what are side effects of clomiphene

Answer 6

blurred visions and headaches - stop immediately if develop

Question 7

what is the biggest risk with climphene

Answer 7

10 percent multiple pregnancy rate - good practice to ultrasouns scan during the first month of use to make sure not too many dominant follicles develop

Question 8

what is the max dose of clomiphene

Answer 8

150mg daily

Question 9

what is the maximum number of cycles of clomiphene

Answer 9

6 months or six cycles due to possible risks of ovarian cancer with prolonged use

Question 10

why is metformin used in PCOS

Answer 10

women with PCOS often have insulin resistance
advantageous as promoted mono ovulation so reduced the chance of multiple pregnancy we used alongside clomiphene
however, recent NICE metaanalysis found no differenct in live birth rates between clomiphene alone and clomiphene combined with metformin

Question 11

What is laparoscopic ovarian drilling

Answer 11

ovaries are drilled using diathermy for a few seconds in multiple places

Question 12

what is advantageous aout LOP

Answer 12

can do other procedures at same time eg remove endometriosis tissue, do Lap and dye
encourages mono ovulation so low risk of multiple pregnancy
effects can last for many years after treatment

the drilling is thought to disrupt ovarian stroma and appears to reset the miliu allowing folliculargenesis to commence but how it works exactly us unclear

Question 13

When is gonadotrophin therapy used in PCOS

Answer 13

gonadotrophin injections daily can be used as second line treatment for PCOS instreas of lop

but high risk of multiple pregnancy - 20 percent
using low dose step up method in a low dose is used for 10 days and then ultrasound is used to see if a more than 10mm follicle has developed, same dose is continued for a few days and then a further can confirms presense of prevulatory follicle. trigger is given followed by timed intercourse - this reduces MP rates to around 10 percent

Question 14

what assisted conception treatment do women with PCOS receive

Answer 14

IVF

Question 15

how is group 3 anovulation treated

Answer 15

require donar gametes
adoption
accepting childlessness

Question 16

what drugs can be given to treat hyperprolatinaemia

Answer 16

bromocriptine

Question 17

how are group 1 ovulation disorders treated

Answer 17

address cause ie increase BMI, reduce exercise
pulsatile subcut GNRH via pump
also can induce ovulation with gonadotrphin injections daily for two weeks - should use menipur and has LH and FHS then give HCG and timed intercourse. monitor with ultrasound to reduce risk of multiple pregancy

Question 18

how are women with tubal disease treated

Answer 18

IVF primarlity and remove hydrosalpinx if present and this will improve success (hydrosalpinx been shown to alf rates of IVF success
surgery to unblock tube may be beneficial in tubal cannulation
if only one tube blocked and no hydrosalpinx then can leave

Question 19

what is ashermans syndrome

Answer 19

extensive uterine adhesions

causes usually retained placenta after delivery or endometrial curettage for a miscarriage

Question 20

what is the namefor the process of removing fibroids

Answer 20

myomectomy

Question 21

when should fibroids be removed

Answer 21

submucosal and distrupting uterine cavity
very large ones greater than 5cm
can do TCRF for smaller fibroids less than 3cm, but must do laparoscopy for women with bigger fibroids

in general population out with fertility NICE guidline only recommend removal if symptomatic and greater than 3cm

Question 22

how is endometriosis treated

Answer 22

ablation of endometrial tissue and removal of cyst shown to improve natural pregnancy rate

unclear of cyst removal should be done prior to IVF

often best treatment is IVF

Question 23

what is the risks of having an endometrioma during IVF

Answer 23

may make oocyte recovery difficult - rupture during this procedure may cause infection and pelvic absess
antibiotics should be given in this case

Question 24

what protocol is beneficial for women with severe endometriosis for IVF

Answer 24

ultralong protocol

prolonged downregulation for 2-3 months

Question 25

what is the treatment for unexplained infertility

Answer 25

no place for stimulation with clomiphene etc.
expectant management if no know pathology and under the age of 36 until 2 years of infertility. women over the age of 36 can be seen sooner for ivf treatment.
if ovarian reserve is extremely low may not be ale to offer any treatment without donor

Question 26

why is IUI not preferred

Answer 26

not shown to have greater success than trying naturally
unless stimulated but this has high multiple pregnancy rate and often procedure is cancelled if there is more than two mature follicles seen on ultrasound