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Obs & Gynae > Fertility > Flashcards

Fertility Flashcards

1
Q

What is the definition of subfertility?

A

If conception has not occurred after 12 months of regular unprotected intercourse

Primary - female has never conceived
Secondary - previous conceived even if it resulted in miscarriage or termination

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2
Q

What conditions are required for pregnancy?

A

Egg must be produced (30%)
Adequate sperm release (25%)
Sperm must reach egg/fallopian tube blockage (25%)
Fertilised egg must implant (30%)

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3
Q

What causes the decline in female fertility?

A

Reduced genetic quality of remaining oocytes

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4
Q

What occurs during ovulation?

A

High levels of FSH cause maturation of several follicles which produce more oestrogen
Intermediate oestrogen has negative feedback effect so less LH and FSH are produced
Maturing follicles compete for stimulating hormone and only dominant follicle has enough gonadotrophin receptors to continue
Increased oestrogen causes positive feedback so more FSH and LH -> rupture of follicle

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5
Q

How is ovulation detected?

A

Spotting/discharge/mittelschmerz

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6
Q

What are cases of anovuation?

A 
PCOS
Hypothalamic hypogonadism
Hyperprolactinaemia
Thyroid disease - reduce fertility
Androgen secreting tumours - cause virilisation
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7
Q

What is a polycystic ovary?

A

Characteristic transvaginal USS appearance of multiple small follicles in an enlarged ovary
20% of all women
Majority have normal cycles

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8
Q

What is polycystic ovarian syndrome?

A

Women with PCO who put on weight
5% of women
80% of anovulatory infertility

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9
Q

What are the diagnostic criteria for PCOS?

A 
PCO on USS
Irregular periods (>35 days apart)
Hirsutism: clinical (acne, excess body hair) or biochemical (raised testosterone)
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10
Q

What is the pathology of PCO?

A

Disordered LH production and peripheral insulin resistance
Increased LH and insulin act on PCO causing increased adrenal androgen production and reduced hepatic production of steroid hormone binding globulin
Therefore increased free androgens

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11
Q

What does increased androgens cause in PCOS?

A

Disrupt folliculogenesis -> excess small ovarian follicles and irregular ovulation
Hirsutism

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12
Q

What is the link between body weight and androgen levels in PCOS?

A

Increased body weight leads to increased insulin resistance therefore increased insulin -> androgens

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13
Q

How does PCOS present?

A 
Obesity
Acne
Hirsutism
Oligo/amenorrhoea
Increased miscarriage
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14
Q

How is PCOS investigated?

A

Blood tests

  • normal FSH
  • normal prolactin
  • normal TSH
  • raised testosterone
  • raised LH

USS
- PCO

Other
- screen for diabetes and abnormal lipids

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15
Q

How does the level of FSH differentiate causes of anovulation?

A

Raised in ovarian failure
Low in hypothalamic disease
Normal in PCOS

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16
Q

What are complications of PCOS?

A

50% develop type II diabetes
30% develop gestational diabetes
Endometrial cancer - unopposed oestrogen action

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17
Q

How is PCOS treated?

A

Diet and exercise
COCP will regulate menstruation and treat hirsutism - need 3-4 bleeds/year
Antiandrogens (cyroterone acetate or spironolactone)
Metformin - reduces insulin therefore androgens and hirsutism

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18
Q

What is hypothalamic hypogonadism?

A

Reduction in GnRH production reduced stimulation of pituitary, reduces FSH and LH levels and reduces oestrogen

ANOREXIA NERVOSA
Diets
Athletes
Stress

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19
Q

What is Kallmann’s syndrome?

A

GnRH secreting neurones fail to develop

20
Q

What causes prolactinaemia?

A 
Benign tumour (adenoma)
Hyperplasia of pituitary cells
PCOS
Hypothyroidism
Psychotrophic drugs
21
Q

How does prolactinaemia present?

A 
Reduces GnRH so cascade is reduced
Oligo/amenorrhoea
Galactorrhoea - milky discharge from nipples
Headaches
Bitemporal hemianopia
22
Q

How is prolactinaemia treated?

A

Dopamine agonist
Bromocriptine
Cabergoline

23
Q

How does pituitary damage affect ovulation?

A

Reduces FSH and LH release

Can result from pressure from tumour or infarction following PPH (Sheehan’s syndrome)

24
Q

What are ovarian causes of anovulation?

A

PCOS
Premature ovarian failure
Luteinised unruptured follicle syndrome - follicle develops but isn’t released

25
Q

How is ovulation induced in PCOS?

A

Clomifene - use for 6 months
Antioestrogen - blocks receptors in hypothalamus and pituitary so oestrogen cannot inhibit release of FSH and LH
Given days 2-6 of cycle to cause follicle to mature

Monitor via transvaginal USS to check endometrium doesn’t thin
Can cause multiple pregnancies
Increase up to 150mg/day

26
Q

What are second line treatments for PCOS?

A

Metformin - used with clomifene to increase effectiveness

If continued during pregnancy, decreases risk of early miscarriage and gestational diabetes

27
Q

What is the treatment ladder for inducing ovulation?

A 
Weight loss and lifestyle changes
Clomifene
Metformin
Gonadotrophins
Ovarian diathermy
IVF
28
Q

How does surgery improve anovulation?

A

Each ovary is diathermied for a few seconds and tubal patency tested at same time

29
Q

How are hormones used to improve anovulation?

A

Recombinant FSH +/- LH are given in step up doses every 5-7 days
USS of ovaries and when large enough, hCG is given

30
Q

What are side effects of ovulation induction?

A

Multiple pregnancy - with clomifene or gonadotrophins
Ovarian hyperstimulation syndrom
Ovarian and breast carcinoma

31
Q

What stimulates spermatogenesis?

A

LH stimulates production of testosterone in Leydig cells of testis
FSH and testosterone control Sertoli cells which synthesis and transport sperm

32
Q

What is normal semen analysis?

A

> 1.5ml volume
15 million/ml sperm
32% progressive motility

33
Q

What causes an abnormal sperm analysis?

A 
Smoking
Alcohol
Drugs
Chemicals
Inadequate cooling
Varicocoele
Antisperm antibodies
34
Q

How is male subfertility investigated?

A

Semen analysis is repeated after 12 weeks

Blood test - FSH, LH, testosterone, prolactin, TSH, cystic fibrosis

35
Q

What causes disorders of fertilisation?

A

Tubal damage - infection, endometriosis, adhesions
Cervical problems
Sexual problems

36
Q

How are disorders of fertilisation treated?

A

Laparoscopic addhesiolysis and salpingostomy

37
Q

How are problems with fertilisation detected?

A

Laparoscopy and dye test

Hysterosalpingogram

38
Q

What are indications for assisted conception?

A 
Failure of other methods
Unexplained subfertility
Male factor subfertility
Tubal blockage
Endometriosis
39
Q

What is intrauterine insemination?

A

Washed sperm are injected into uterus

Done after urine LH test or gonadotrophin ovulation induction

40
Q

What is IVF?

A

Embryos are fertilised outside uterus and then transferred back

41
Q

What hormones are given before IVF?

A

2 weeks of daily sub-cut gonadotrophin injections

Then hCG or LH given and 35 hours later egg is collected

42
Q

What is ICSI?

A

Intracytoplasmic sperm injections

IVF plus sperm is injected into oocute

43
Q

How does OHSS present?

A 
Hypovolaemia
Electrolyte disturbances
Ascites
Thromboembolism
Pulmonary oedema
44
Q

How is OHSS treated?

A 
Intravascular volume restoration
Electrolyte monitoring
Analgesia
Thromboprophylaxis
Drain ascites fluid
45
Q

What is OHSS?

A

Gonadotrophins (LH + FSH) overstimulate follicles

Cause large and painful

46
Q

What are risk factors for OHSS?

A

Age less than 35

PCO

Obs & Gynae (20 decks)

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