Fertility + early pregnancy Flashcards
What is the differential diagnosis of abdominal pain after oocyte collection?
Procedural complication - haemorrhage, bowel injury
Infection
OHSS
Torsion
Ectopic
Haemorrhagic cyst
Other e.g. appendicitis
Outline considerations for haemorrhagic cyst in pregnancy
Differential diagnosis considered
Consent - include oophorectomy, miscarriage
Not instrumenting uterus
Laparoscopic ports insertion, fundus may be enlarged
Thorough survey
Little as possible to ovary as may disrupt corpus luteum, mindful about diathermy on ovary with future fertility
Document
Debrief
FHR assessment pre and post op
VTE prophylaxis
BhCG surveillance vs viability USS in one week
Counsel regarding Asherman’s syndrome
Where it may have come from e.g. uterine instrumentation
Risks - amenorrhoea/irregular bleeding, infertility, miscarriage, placenta praevia and accreta, IUGR
Management - surgical correction via hysteroscopy +/- laproscopy guidance as perforation risk. Done by specialist. IUCD or progesterone for set period of time to prevent reformation
Investigations for infertility
Day 3 FSH, LH
Oestradiol
Mid luteal “Day 21” progesterone
Testosterone
SHBG
Androstenedione
17-OHP
Prolactin
TSH, T4
Antenatal bloods
Semenalysis (repeat if abnormal)
USS pelvis
Tubal patency - HSG, Sonohysterogram, HyCoSy
Laparoscopy - endometriosis, tubal patency with methylene blue
OHSS
History and examination
History:
- Ovarian stimulation cycle 7-10 days prior
- Medication used for trigger (hCG or GnRH agonist)
- Number of follicles on monitoring scan
- Number of eggs collected
- Were embryos replaced and how many?
- PCOS hx
- Abdominal pain
- Abdominal distension
- Nausea and vomiting
- Diarrhoea
- SOB ?positional
- Vulval swelling
- Low urine output
- VTE: swollen/sore calf; PE sx
Examination:
- General: dehydration, oedema, observations, body weight.
- Abdo: ascites, masses, peritonism, abdo girth
- Respiratory: pleural effusion, pneumonia, pulmonary oedema
OHSS
Investigations and management
Investigate:
BhCG
CBC - Hct, WCC
Creatinine
Electrolytes
LFTs
CXR
USS pelvis - pregnancy, torsion ,cysts, rupture, free fluid, stimulation
Consider CT-PA, V/Q, ABG
Management:
MDT - Fertility, Haematology, respiratory, renal. May need ICU. Social support.
Mild/moderate - OP follow up, avoid strenuous exercise, intercourse
Severe or critical - ADMIT
Analgesia (no NSAIDs), antiemetics
O2 supplement
Fluid balance - daily weighs, abdominal girth
IDUC, UO monitor
IVFs
VTE prophylaxis - clexane, TEDs
Daily bloods
Consider paracentesis, pleurocentesis
Consider dopamine infusion
Follow up BhCG if embryo transfer
How is endometriosis managed with respect to inferility?
Investigation, treatment
AMH - indication on ovarian reserve if surgery is planned
Tubal patency investigation - HSG, sonohysterogram, HyCoSy, methylene blue if laparoscopy
Assess other causes of fertility delay - semen analysis
Laparoscopy
- consider if Hx of pain, need to obtain histological diagnosis
- benefit for stage I to II
- consider III to IV - only prior to ART if assists with oocyte collection access or for symptom control. Must counsel re effect on ovarian reserve
ART
- lower threshold if AMA
- tubal disease
- if unable to concieve >12m
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You have performed a salpingectomy for an ectopic pregnancy. Histology shows normal tube and no ectopic. How do you proceed?
Review case - history,exam, investigations
Consider Ddx - tubal abortion, wrong tube, abdominal pregnancy, other reason for elevated BhCG
Current symptoms - pain, bleeding, dizziness
Examination
Bloods - BhCG, Hb
Repeat USS
Options - conservative, MTX, repeat laparoscopy
If has BL salingectomy - impact on fertility
Document
Open disclosure
Escalate to senior involvement
Psychological support
Investigations for infertility show azoospermia - how do you proceed?
History, exam, investigations
History:
Sample obtained appropriately
Fathered any other children
Childhood development
Libido, ejaculation difficulty
Infections e.g. mumps, STIs
Trauma to area, hx of torsion
Toxin exposure - chemo, radiation, environmental
PMHx
Medications incl steroids
FHx e.g. CF
Social - smoke, vape, alcohol, recreational drugs. Occupation and any exposures. Hobbies e.g. cycling
Examination:
BMI
Obs
General appearance
Hair distribution
Abdomen and groin - scars, palpate for hernia or undescended testis
Testis - appearance, volume, contour, varicocoele or hydroceole. Gynaecomastia. Palpate vas deferens
Investigation:
REPEAT sample 12weeks
Testicular USS
FSH, LH, testosterone, PRL, TSH
Karyotype + Y chromosome analysis
CF screen (genetic counselling, screen female if positive)
STI swabs
Testicular biopsy
?post ejaculation urine sample
Azoospermia differential diagnosis
Obstructive - normal FSH, normal testosterone
* Absent vas deferens e.g. CF
* STI
* Previous vasectomy
Non-obstructive - high FSH, low testosterone
* Infection e.g. mumps
* Chemotherapy
* Previous torsion
* Undescended testis in childhood
* Klinefelter
Non-obstructive - low FSH, low testosterone
* Kallman syndrome
* Pitutary
Azoospermia - management with respect to fertility
Sperm retrieval
IVF with ICSI
Donor sperm
Adoption
Differential diagnosis for uterine size 14/40 when only 11/40 by dates?
Incorrect dates
Multiple gestation
Molar pregnancy
Fibroids
Fetal pathology
Infertility history and examination
Female
History:
Duration of trying
Frequency of intercourse, knowledge of fertile window
Sexual difficulties - arousal, pain
Medical, surgical, psychiatric history
Gravity/parity
Smears, Hx of STIs
Periods - onset, frequency, duration, regularity, IMB, PCB, assoc pain
ROS - pain, bladder, bowels, headaches/vision changes, sense of smell
Medications, allergies - contraception, OTC
Social - home, relationship, occupation and exposures, smoking, vaping, alcohol, other substances
Family history
Examination:
Observations
BMI
Stature and appearance
Cardiovascular, respiratory, breast, thyroid
Abdomen
Vulva/vagina - normal, lesions, hair distribution, virlisation, FGM.
Speculum and bimanual
On investigation for azoospermia the male is found to be homozygous for deltaF508 mutation. His female partner is heterozygous fore the same. How do you counsel?
Mutation is consistent with CF - autosomal recessive condition so he is affected and she is a carrier.
Explains azoospermia from absent vas deferens.
Health implications for him - refer to geneticist and respiratory for management.
Fertility implications of azoospermia - need sperm retrieval, IVF and ICSI
Genetic implications for couple - 50% chance of affected child and 50% chance child will be carrier. Can do IVF with PIGD to ensure unaffected embryo transferred (would still be a carrier).
If doesn’t do PIGD then can do NIPT or invasive test (CVS or amnio) in pregnancy with option for TOP if affected
Other options include gamete donation (from either, would need CF screen first) or adoption.
List investigations for recurrent pregnancy loss
- USS pelvis - uterine anomaly
- HbA1c
- TFTs
- Day 2 FSH, LH
- Oestradiol
- Antiphospholipid antibodies - antibeta2glycoprotein1, anticardiolipin, lupus anticoagulant (repeat 12weeks if strongly +ve)
- (Thrombophilia screen now controversial, low yield if no FHx of VTE or same)
- Parental karyotype also controversial - better to send any future POC for analysis for translocation and screen parents if +ve
