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HD 2 > Fertility > Flashcards

Fertility Flashcards

1
Q

Define infertility.

A

A disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.

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2
Q

Define primary infertility.

A

When a woman is unable to ever bear a child, either due to the inability to become pregnant or the inability to carry a pregnancy to a live birth she would be classified as having primary infertility.

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3
Q

Define secondary infertility.

A

When a woman is unable to bear a child, either due to the inability to become pregnant or the inability to carry a pregnancy to a live birth following either a previous pregnancy or a previous ability to carry a pregnancy to a live birth.

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4
Q

What are the causes of female infertility? (4)

A

Ovulatory Disorders
Tubal Damage
Uterine/peritoneal disorders
Unexplained infertility

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5
Q

How many % of cases of infertility have male factors?

How many have both female and male factors?

A

30%

40%

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6
Q

What are the three types of ovulatory disorders that cause infertility?

A

Type 1: Hypopituitary Failure (e.g. due to anorexia nervosa)

Type 2: Hypopituitary Dysfunction (eg PCOS, hyperprolactinaemia)

Type 3: Ovarian Failure (premature if under 40 yrs)

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7
Q

What are polycystic ovaries?

A

10 or more follicles per ovary on ultrasound

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8
Q

What are the diagnostic criteria for PCOS? (3)

A

Clinical hyperandrogenaemia
Oligomenorrhoea
Polycystic ovaries on ultrasound

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9
Q

What are the signs and symptoms of PCOS?

A 
Menstrual disturbance (oligomenorrhoea, amenorrhoea, DUB)
Infertility
Hirsutism
Acne
Male-pattern hair loss
Central obesity
Acanthosis nigricans
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10
Q

What can be seen on the blood test results in those with PCOS?

A 
Raised LH with normal FSH
Raised Testosterone (with or without reduced SHBG)
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11
Q

What are the differential diagnoses for PCOS that must be excluded? (4)

A

Thyroid dysfunction
Congenital adrenal hyperplasia
Hyperprolactinaemia
Androgen-secreting tumours

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12
Q

How does PCOS affect metabolism?

A

Abnormal serum lipid concentrations
Insulin resistance
Increased risk of developing diabetes mellitus

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13
Q

What are the tubal/uterine causes of infertility? (5)

A 
Pelvic Inflammatory Disease
Previous tubal Surgery
Endometriosis (tubal and uterine)
Fibroids (uterine)
Cervical mucus defect
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14
Q

Pelvic inflammatory disease - how many % develop tubal infertility after 1 episode? How many after 3 episodes?

A

More than 10%

50%

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15
Q

What are the symptoms of an acute PID episode? (5)

A 
Pelvic pain
Deep dyspareunia
Malaise
Fever
Purulent vaginal discharge
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16
Q

What causes chronic PID?

A

Inadequately treated acute PID

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17
Q

How is PID managed?

A

Rest
Abstinence
Antibiotics

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18
Q

What can be found on examination of PID?

A

Cervical excitation
Adnexal tenderness
Discharge
Pyrexia

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19
Q

What investigations are done for PID?

A

Smear - microscopy, culture and sensitivies plus chlamydia

FBC - raised ESR

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20
Q

What is endometriosis?

A

Presence of tissue histologically similar to endometrium outside the uterine cavity and myometrium (most commonly found in the pelvis).

Pain, dysmenorrhoea, menorrhagia, dyspareunia
Ex: pelvic tenderness or mass, fixed uterus.
Note laporoscopic findings common and don’t correlate to pain.

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21
Q

What are the risk factors for endometriosis? (3)

A

Increased risk with age, frequent cycles, family history

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22
Q

What protects against endometriosis? (2)

A

Combined oral contraceptive pill

Pregnancy

23
Q

How is endometriosis managed?

A

NSAIDs for pain
Norethisterone or COCP
Danazol and GnRH agonists
Surgery

24
Q

What are (uterine) fibroids?

A

Uterine leiomyoma - benign tumours of the smooth muscle of the myometrium.

25
Q

What do women with fibroids often complain of?

A

Heavy (regular) periods

26
Q

How are fibroids treated?

A

Tran Acid
Combined oral contraceptive pill/long acting reversible contraceptives
Surgical resection

27
Q

What are the male causes of infertility? (5)

A

Testicular (infection, cancer, surgical, congenital, undescended testes and trauma)
Azoospermia (+/- sperm antibodies)
Reversal of vasectomy
Ejaculatory problems (retrograde and premature)
Hypogonadism

28
Q

What drugs are linked to infertility in women?

A 
Long term NSAID use
Chemotherapy
Neuroleptics
Spironolactone
Depo-provera
Marijuana, cocaine, and other illicit drugs
29
Q

What drugs are linked to infertility in men?

A

Sulfasalazine
Anabolic steroids
Chemotherapy
Chinese herbs for improving sperm count and motility
Marijuana, cocaine, and other illicit drugs

30
Q

If a couple has been trying to conceive for less than two years, they are not referred to a specialist. When might earlier referral be considered?

A

If the woman is aged 36 years or over

If there is a known clinical cause of infertility or a history of predisposing factors for infertility

31
Q

What tests are done by the GP before a specialist referral?

A 
Full Sexual/Contraception/Fertility History
PCOS screen (day 21 progesterone, LH, FSH, serum testosterone, glucose)
FBC
Thyroid function tests/TSH
Vitamin D
HbA1c
Viral screen (rubella, HIV, hepatitis)
STI screen
Check smear up to date
Semen analysis
32
Q

What three things does a semen analysis look for?

A

Volume (ml) - LRL 1.5ml
Progressive Motility (%) - LRL 32%
Morphology (%) - LRL 4% normal

33
Q

What tests may be done in secondary care to investigate infertility?

A

Ovarian reserve testing (it tests how you would respond to gonadotrophin stimulation in IVF)

HSG, HyCoSy (to assess tubal function)

Laparoscopy (to assess uterine function)

34
Q

How are type 1 ovulatory disorders managed?

A

Increase weight, decrease exercise.

Consider pulsatile GnRH or Gn with LH activity to induce ovulation.

35
Q

How is PCOS-related infertility managed?

A

Weight loss to BMI of 30 or below
Clomiphene or metformin - first line
Combined clomiphene and metformin, laparoscopic ovarian drilling and Gn therapy - second-line

36
Q

How is hyperprolactinaemia managed?

A

Bromocriptine

37
Q

How are type 3 ovulatory disorders managed?

A

Consider donor eggs or alternataive parenting strategies

38
Q

How is tubal/uterine infertility managed?

A

Laproscopic tubal surgery - catheterisaton/cannulation
Surgery (fibroid/endometriosis clearance)
Adhesiolysis
Treatment of endometrosis

39
Q

How is hypogonadism treated?

A

Gonadotrophins

40
Q

What are the NHS guidelines for unexplained fertility management?

A

Do not offer clomiphene
Advise to continue having regular unprotected intercourse for 2 years (investigations after 1 year)
Offer IVF after 2 years

41
Q

How is intrauterine insemination done?

A

Sperm is separated in lab and the slower speed sperm are removed before the partner is inseminated (via vaginal speculum and small catheter inserted into womb).
Insemination takes place on day 12-16 in women who aren’t on ovarian stimulating drugs. If they are on these drugs, vaginal ultrasounds are used to track the eggs - when the egg is mature, LH is injected to stimulate release and insemination is done 36-40 hours later.

42
Q

Who is IUI offered to?

A

People unable to have vaginal intercourse
Those requiring specific consideration (eg sperm wash in HIV positive men)
Same-sex relationships

43
Q

How many cycles of IUI are offered before IVF?

A

12 cycles

44
Q

Who is IVF offered to?

A

Women under 40 who have not conceived after 2 years of unprotected intercourse or 12 cycles of artificial insemination (6 IUI)
OR
Women between 40-42 who have not conceived after 2 years, 12 cycles of AI, never previously had IVF, no evidence of low ovarian reserve)

45
Q

How many cycles of IVF are offered to women?

A

3 full cycles

1 cycle offered to 40-42 year old women

46
Q

What are the stages of IVF?

A
  1. Suppressing the natural monthly hormone cycle via daily injection or a nasal spray (for about two weeks).
  2. Boosting the egg supply with gonadotrophins (daily injection for around 12 days).
  3. Checking on progress through vaginal ultrasound scans and blood tests. Between 34 and 38 hours before eggs are due to be collected woman given a hormone injection to help eggs mature.
  4. Collection of the eggs using ultrasound guidance while sedated. Collection of sperm sample-washed and prepared/frozen.
  5. Eggs will be mixed with sperm and cultured in the laboratory for 16–20 hours after which they are checked for signs of fertilisation. Those that have been fertilised will be grown in the laboratory incubator for up to six days. The embryologist will monitor the development of the embryos and the best will then be chosen for transfer.

Step 6. One or two embryos may be transferred if under 40, a maximum of three may be used if 40 years or over.

47
Q

What are predictors of more successful outcome in IVF?

A

Age, less cycles, previous pregnancies, BMI 19-30, no smoking, no ectopic pregnancies, no caffeine.

48
Q

What is intracytoplasmic sperm injection/how is it done?

A

Embryologist selects a single sperm to be injected directly into an egg.

49
Q

When is ICSI indicated?

A

Severe deficits in semen quality
Obstructive or non-obstructive azoospermia
IVF has failed/resulted in poor fertilisation

50
Q

What genetic issues should be considered with ICSI?

A

Karyotype for Kallman’s

Microdeletions on Y-chromosome

51
Q

What is the benefit of ICSI compared to IVF?

A

Improves rate of fertilisation

52
Q

What is a potential consequence of drugs used to stimulate ovarian function, such as gonadotrophin or clomifene?

A

Ovarian hyperstimulation syndrome

53
Q

What are the signs and symptoms of mile and severe ovarian hyperstimulation syndrome?

A

Mild: Lower abdo discomfort/distention, with or without nausea.

Severe: Abdo pain/distention, ascites, pleural effusion, venous thrombosis

54
Q

What does IVF give a small increased risk of?

A

Borderline ovarian tumours

HD 2 (25 decks)

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