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Year 2 Clinical > Assessment and Management of Infertility > Flashcards

Assessment and Management of Infertility Flashcards

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1
Q

Occurrence of infertility?

A

Common and half of the couples affected conceive either spontaneously or with relatively simple advice/treatment

Some remain sub-fertile and require more complex treatment, e.g: assisted conception techniques

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2
Q

Incidence of inferility increases in?

A
  • Older women (decreased fertility, increased spontaneous abortions)
  • Rise in Chlamydia infections (can cause tubule blockage)
  • Obesity (less likely to ovulate)
  • Change in expectations (same-sex marriage)
  • Awareness of treatments
  • Male factor infertility
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3
Q

Describe chances of spontaneous pregnancy

A

Increase over the months until 12 months

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4
Q

Definition of infertility?

A

Failure to achieve a clinical pregnancy after 12 months/ more of regular unprotected sexual intercourse (in absence of known reason) in a couple who have never had a child

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5
Q

2 types of infertility?

A

Primary - couple have never conceived

Secondary - couple previously conceived, although the pregnancy may not have been successful, e.g: miscarriage or ectopic pregnancy

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6
Q

Factors that increase the chance of conception?

A
  • Woman <30 years
  • Previous pregnancy
  • <3 years trying to conceive
  • If there is an unexplained cause
  • Intercourse during 6 days before ovulation, part. 2 days before ovulation
  • Woman’s BMI 20-30
  • Both partners non-smokers
  • Caffeine intake (<2 cups of coffee daily)
  • No use of recreational drugs
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7
Q

Causes of infertility in couple having IVF/ICSI?

A

Can be:

  • Unexplained
  • Tubal disease (secondary infertility is more common here)
  • Endometriosis
  • Uterine factor
  • Male factor infertility
  • Multiple factors can cause infertility

Each of these have primary and secondary sub-types

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8
Q

What is anovulatory infertility?

A

The person is infertile and their ovaries do not release an egg

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9
Q

Physiological causes of anovulatory infertility?

A

Before puberty, pregnancy, lactation and menopause

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10
Q

Gynaecological causes of anovulatory infertility?

A

Hypothalmic:

  • Anorexia/bulimia
  • Excessive exercise

Pituitary:

  • Hyperprolactinaemia
  • Tumours
  • Sheehan’s syndrome
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11
Q

Other causes of anovulatory infertility?

A

Systemic disorder, e.g: chronic renal failure

Endocrine disorder, e.g: testosterone-secreting tumours, CAH and thyroid problems

Drugs, e.g: depo-provera, explanon, OCP

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12
Q

WHO classification of anovulatory disorders?

A

Group 1 - AKA hypothalamic amenorrhea, inc:

  • Stress, excessive exercise, anorexia
  • Kallman’s syndrome
  • Isolated gonadotrophin deficiency

Group 2 - AKA hypothalamic-pituitary dysfunction; normogonadotrophic-normoestrogenic-anovulation:

• PCOS

Group 3 - AKA ovarian failure, inc. all variants of ovarian failure and resistant ovary

Other causes include hyperprolactinaemia

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13
Q

Success of ovulation induction in the different groups of ovulatory disorders?

A

Ovulation can be induced in group 1 & 2 but is usually unsuccessful in group 3 (tends to require oocyte donation)

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14
Q

Occurrence of anorexia nervosa?

A

More common in females; there is an uncertain aetiology

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15
Q

Clinical features of anorexia nervosa?

A

Low BMI (<18.5)

Loss of hair and increased lanugo (fine hair)

Low pulse and BP

Anaemia

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16
Q

Ix hormone results in anorexia nervosa?

A

Low FSH, LH and oestradiol, i.e: they develop hypogonadortrophic hypogonadism

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17
Q

Occurrence of polycystic ovary syndrome (PCOS)?

A

Most common cause of anovulatory infertility; it is an inherited condition but weight gain exacerbates it

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18
Q

Clinical features of PCOS?

A

Obesity (usually, central so waist : hip ratio is increased)

Acne/oily skin

Hirsutism

Cycle abnormalities and infertility

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19
Q

Ix biochemistry in PCOS?

A

Biochemical tests (day 2-5):

High testosterone/free androgen index

High LH

Normal oestrogen

Impaired glucose tolerance (higher risk of DM)

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20
Q

What is the diagnosis of PCOS based on?

A

Score 2 out of 3 in the Rotterdam criteria:

  • Chronic anovulation
  • Polycystic ovaries (on USS)
  • Hyperandrogenism (clinical or biochemical)
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21
Q

USS appearance of polycystic ovaries?

A

Increased ovarian volume (>10 ml)

>12 follicles, between 2-8 mm in diameter, in a single plane (a necklace pattern) and they tend to be peripherally located; can be unilateral or bilateral

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22
Q

Treatment of PCOS?

A

1st line treatment:

• Anti-oestrogens - Clomifene citrate OR Tamoxifen

2nd line treatment:

• Aromatase inhibitors - Letrozole (unlicensed)

If this fails, ask the patient to lose weight OR:

  • Clomifene citrate + Metformin (to improve sensitivity)
  • Gonadotrophin daily injections
  • Laparoscopic ovarian diathermy
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23
Q

Use of Clomifene citrate?

A

Used from days 2-6, for 5 days, with a maximum dose of 150 mcg/day; it induces ovulation in the majority of patients but only 1/2 conceive

Monitored with an ovulation tracking scan and luteal phase serum progesterone

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24
Q

Occurrence of premature ovarian failure?

A

Occurs <40 years of age, i.e: it is premature menopause (although this term is discouraged)

Can be:

  • Idiopathic
  • Genetic, e.g: Turner’s syndrome (mosaic, where 1 chromosome is normal and the other is abnormal), fragile X
  • Chemo/radiotherapy
  • Oophorectomy
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25
Clinical features of premature ovarian failure?
Hot flushes and night sweats Atrophic vaginitis
26
Ix hormones in premature ovarian failure?
High FSH and LH Low oestradiol
27
What is tubal disease?
Anything that cause blockage
28
Infective causes of tubal disease?
* Pelvic inflammatory disease, like STIs (e.g: chlamydia, gonorrhoea) and others (e.g: anaerobes, syphilis, TB) * Transperitoneal spread, e.g: appendicitis (can cause adhesions if rupture occurs), intra-abdominal abscess * Following procedure, e.g: IUCD insertion, hysteroscopy, HSG
29
Short-term effects of pelvic inflammatory disease?
* Tubo-ovarian abscess * Peritonitis * Fitz-Hugh-Curtis syndrome - liver capsule inflammation leading to the creation of adhesions
30
Long-term effects of pelvic inflammatory disease?
* Chronic pelvic pain * Hydrosalpinx (distally blocked fallopian tube filled with fluid) causes infertility; it creates a characteristic sausage-shaped fallopian tube and this must be operated on * Ectopic pregnancy
31
Non-infective causes of tubal disease?
* Endometriosis * Surgical causes (e.g: sterilisation, ectopic pregnancies) * Fibroids * Polyps * Congenital * Salpingitis isthmica nodosa (diverticulosis of the fallopian tube) - nodular thickening of narrow part of the fallopian tube due to inflammation
32
Clinical features of pelvic inflammatory disease?
* Abdominal/pelvic pain * Febrile * Vaginal discharge and cervical excitation * Dyspareunia (painful intercourse) * Menorrhagia (abnormally heavy or prolonged periods) and dysmenorrhea (painful periods) * Infertility * Ectopic pregnancy
33
What is endometriosis?
Presence of endometrial glands outside the uterine cavity; incidence is higher in infertile women and it is assoc. with impaired infertility Retrograde menstruation is the most likely cause; other inc: * Altered immune function * Abnormal cellular adhesion molecules * Genetic
34
Clinical features of endometriosis?
Dysmenorrhoea (classically before menstruation) and menorrhagia Dysparenuia and painful defaecation Chronic pelvic pain
35
Ix for endometriosis?
USS may show characteristic ‘chocolate’ cysts on ovary, infertility, asymptomatic; uterus may be fixed and retroverted Histopathology shows an active, typical glandular endothelium with active proliferation and secretory changes Laparoscopic view
36
Why do chocolate cysts occur?
Endometrium wraps around and bleeds into the ovaries
37
Male causes of infertility?
Hypothalmic pituitary Testicular disease Obstruction/transport Unexplained Other causes
38
Endocrine causes of male infertility?
1. Hypogonadotropic hypogonadism, e.g: * Kallmann's syndrome * Anorexia 2. Testicular failure: * Klinefelter’s syndrome (47 XXY) * Chemo/radiotherapy * Undescended testes * Idiopathic 3. Hyperprolactinaemia (macro/microadenoma) 4. Acromegaly 5. Cushing’s disease 6. Hyper/hypothyroidism
39
Causes of obstructive male infertility?
Congenital absence e.g: in cystic fibrosis (CF) Infection Vasectomy
40
Clinical features of obstructive male infertility?
Normal testicular volume Normal secondary sexual characteristics, as sex hormones are normal Vas deferens (normally,it is fairly muscular and can be palpated) may be absent
41
Ix hormones in obstructive male infertility?
Normal, LH, FSH and testosterone
42
Causes of non-obstructive male infertility?
47 XXY Chemo/radiotherapy Undescended tested Idiopathic
43
Clinical features of non-obstructive male infertility?
Low testicular volume Reduced secondary sexual characteristics Vas deferens will be present
44
Ix hormones in non-obstructive male infertility?
High LH and FSH Low oestradiol
45
History questions in infertility presentation?
See as a couple: * Infertility history * Gynaecology * Andrology * Sexual history * Social history (illegal drugs/smoking) * PMH, PSH, POH
46
Examination of a female with infertility?
BMI General, assess body hair distribution and galactorrhoea Pelvic examination (assessment for uterine and ovarian abnormalities/tenderness/mobility)
47
Examination of a male with infertility?
BMI General examinaion, assessing size and position of testes Penile abnormalities Presence of vas deferens and of any varicoceles
48
Ix of a female with infertility?
* Endocervical **swab for chlamydia** * Cervical smear if due * Blood for **rubella** (teratogenic) immunity * **Mid-luteal progesterone** level * For an anovulatory cycle, do an **early menstrual hormone profile** (day 2-5) * Test of **tubal patency** (with hysterosalpingiogram or laparoscopy) * Others if indicated: e.g. hysteroscopy, USS, endocrine profile and chromosomes
49
What do regular and irregular cycle suggest and what should be done in each case?
Regular cycles are highly suggestive of ovulation, although some regular cycles are anovulatory; do a mid-luteal progesterone measurement Irregular cycles usually indicate oligo/anovulation; do an early follicular hormone profile
50
Treatment of an infertile female who is +ve for Chlamydia?
Azithromycin; if allergic, doxycycline
51
How to take a mid-luteal progesterone level?
Take it on day 21 of a 28 day cycle OR 7 days prior to the expected period, in prolonged cycles ## Footnote **Progesterone \> 30nmol/l suggests ovulation**
52
How to interpret results of blood rubella immunity test?
If rubella antibodies are \<10 U/L, the patient is non-immune
53
What is Rubella syndrome?
AKA congenital rubella - physical symptoms manifest in the fetus due to maternal infection; characteristics inc: * Rash at birth * Low birth weight * Microcephaly (small head size) * Heart abnormalities, e.g: patent ductus arteriosus (PDA) * Visual abnormalities, e.g: cataracts * Bulging fontanelle
54
Prevention of rubella in a female attempting to conceive?
Rubella vaccine (MMR) The female must not conceive in the 4 weeks following vaccination
55
Treatment of tubal disease?
Tubal surgery - success depends on: * Amount of healthy tube * If there is both proximal and distal disease * Condition of tubal wall * Presence of adhesions IVF
56
IVF procedure?
On day 1 , following inseminatin, formation of 2 pro-nuclei indicates normal fertilisation Division occurs and, on day 4, compaction occurs to form a macula; on day 5, the blastocyst forms
57
What is a hysterosalpingiogram and when is it used as an Ix?
X-ray used to see if fallopian tubes are patent and if the uterine cavityis normal; it is indicated if there is: * Suspected tubal/pelvic pathology, e.g: PID, endometriosis, adhesions * Nil known risk factors * Laparoscopy contraindicated
58
When is laparoscopy contraindicated?
Obesity, previous pelvic surgery and Crohn's disease
59
When is laparoscopy used?
Possible tubal/pelvic pathology, e.g: PID (pelvic inflammatory disease) Known previous pathology, e.g: ectopic pregnancy, ruptured appendix, endometriosis Hx suggestive of pathology, e.g: dysmerrhoea and dyspareunia Previously abnormal HSG
60
What is a hysteroscopy and when is it used?
Examinate the uterine cavity; ONLY performed in cases where suspected or known endometrial pathology, i.e: uterine septum, adhesions, polyp
61
When is a pelvic USS used?
When: • Abnormality on pelvic examination, e.g: enlarged uterus, adnexal mass • Required from other Ix, e.g: possible polyp seen at HSG
62
Other assessments that can be done if the patient has an anovulatory cycle or infrequent periods?
* Urine HCG (pregnancy test) * Prolactin * TSH * Testosterone and SHBG (sex-hormone binding globulin) * LH, FSH and oestradiol
63
Other assessment that can be done if the patient has hirsutes?
Testosterone and SHBG
64
Other assessments that can be done if the patient has amenorrhea?
• Endocrine profile • Karyotype
65
Treatment of premature menopause?
Counselling and prevention of osteoporosis Oocyte donation Cryopreservation of ovarian tissue (prior to radiotherapy/therapy)
66
Causes of male factor infertility?
Mostly idiopathic Obstructive causes Non-obstructive causes Hormonal causes Others: varicocele, chemotherapy, radiotherapy erectile dysfunction, immunological
67
Obstructive causes of male infertility?
Vasectomy Infection (e.g: chlamydia/gonorrhoea) Congenital absence of vas deferens (e.g: CF)
68
Non-obstructive causes of male infertility?
Undescended testis Orchitis (e.g: mumps) Torsion/trauma Chromosomal, e.g: Klinefelter’s syndrome (47XXY), Kartagener syndrome, Y-chromosome micro deletions
69
Hormonal causes of male infertility?
* Hypogonadotrophic hypogonadism * Hypothyroidism * Hyperprolactinaemia * Testicular cancer
70
Ix of a male with infertility?
**Semen analysis**; this is done twice but over 6 weeks apart: * If abnormal, do an endocrine profile * If severely abnormal / azoospermic, do an endocrine profile + chromosome analysis and screen for CF
71
Normal semen parameters on analysis?
Volume \>1.5 ml pH 7.2-7.8 Concentration \>15x10 to the power of 6 /ml Morphological normal forms of 4% Motility - \>50% WBC - 1x10 to the power of 6 /ml
72
What Ix should be done in a male that has an abnormality on genital examination?
Scrotal USS
73
Treatment of male infertility?
Surgery to obstructed vas deferens Intra-uterine insemination (in mild disease) Intra-cytoplasmic sperm injection (ICSI) Percutaneous Epididymal Sperm Aspiration (PESA), combined with ICSI OR Percutaneous Testicular Sperm Aspiration Donor sperm insemination

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