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Flashcards in Infertility Deck (59):
1

what is a basic definition of infertility

the inability of a couple to conceive within 12 months without the use of contraception

2

what % of couples are able to conceive without problem

for those <40yrs:
80% will conceive within 1 year of trying
half of those who do not in the first year will in the second

3

how many couples experience problems with fertility

1 in 7

4

when should infertility be investigated

if after 1 year of trying there is no pregnancy

5

when should you potentially investigate fertility sooner

if there's a problem e.g.
period irregularity
past medical history
testicular problems
abnormal test results
HIV/Hep B
anxiety

age
<36 yrs after 1 year
35-45 years after 6 months
>45 yrs little can be offered

6

what are the three main queries when it comes to infertility

are there eggs available?
is there sperm available?
can they meet?

7

what should be covered in a female history for infertility

duration of infertility
previous contraception
fertility in previous relationships
previous pregnancies/complications
menstrual history
medical/surgical history
sexual history
previous investigations
psychological assessment

8

what should be covered in a female examination for infertility

weight
height
BMI (kg/m2)
fat and hair distribution
galactorrhoea
abdominal examinaton
pelvic examination

9

what are the implications of a higher BMI >30 on fertility/pregnancy

higher miscarriage rate
lower success of fertility treatment
higher medical complications e.g. HBP, diabetes

10

what does your BMI need to be to qualify for NHS fertility treatment

<30

11

what initial tests should be done for women first presenting with infertility problems

prolactin levels - prolactinaemia - if >1000 assess pituitary gland

androgen levels
- testosterone (T)
- androstendione
- dehydroepiandrosterone (DHA)
- dehydroepiandrosterone sulphate (DHAS)
- 17-OH progesterone
- Sex hormone binding globulin (SHBG)

12

how can hirsutism be measured clinically

look for hirsutism

ferriman gallwey score - from hair distribution on:
upper lips, chin, anterior chest, inner thigh, back

13

how is the ferriman gallwey score interpreted

Score <8 – no hirsutism
8-16 – mild
17-25 - moderate
>25 – severe

14

what are clinical signs of androgen excess

hirsutism
galactorrhoea
acanthosis nigricans

15

what should be looked for in a pelvic exam

masses/fibroids
pelvic distortion
fixed retroversion
tenderness
cervical abnormality
vaginal septum

16

what are the complications of fibroids

pressure symptoms
period problems
infertility

17

what are the different kinds of fibroids

subserosal - outwith the lining of the muscles and uterine cavity - pressure symptoms, press on bladder, pain

intramural - if >1/2cm can interfere with implantation

submucosal - can interfere with implantation

18

what should be covered in a male history for infertility

Previous fertility
Medical history (mumps, testicular descent)
Surgical history
Occupational history
Sexual history (STD)
Previous investigations and treatment (varicocoele repair, vasectomy)
loss of body hair/less frequent shaving (less testosterone)

19

what should be covered in a male examination for infertility

weight
height
BMI (kg/m2)
fat and hair distribution (hypoandrogenism)
abdominal and inguinal examination
genital examination

20

how can the male partners BMI affect fertility

high BMI can have a negative influence of spermatogenesis

21

what can examination of the epididymis show

epididymitis
STDs - chlamydia, gonorrhoea, NSTD

22

what can examination of testicular size show

klinefelter syndrome
hyperspermia

23

what can examination of the vas deferens show

possible CF - mutations and congenital bilateral absence of the vas deferens

NB if azoospermatic - indication to test for CF

24

what can examination of the testes show

testicular tumours
testicular maldescent

25

what is varicocoele and where is it more common

abnormla dilatio anf torsion of the veins in the scrotum
- more common on the left, anatomical drainage different as the they drain to the left renal vein instead of the IVC

26

what can examination of the penis show

hypospadias

27

how do you test for the availability of eggs

test serum progesterone in the mid-luteal phase of the cycle - day 21-28 to confirm ovulation if they have regular menstrual cycles

if irregular cycles - blood tests to measure serum gonadotrophins follicle stimulating hormone (FSH) and luteinising hormone (LH)

28

how do you test for the availability of sperm

computerised semen analysis

29

according to WHO what are the reference vakues of:
semen volume
sperm concetration
total sperm number
progressive motility
total motility
morphologically normal

1.5ml
15 million/ml
39 million
32%
40%
4%

30

what are the baseline investigations for a female partner investigating infertility

rubella immunity
chlamydia
TSH
if periods regular - mid-luteal progesterone (7 days prior to expected period)
if periods irregular - day 1-5 FSH, LH, PRL, TSH, testosterone

31

what are the baseline investigation for a male partner investigating infertility

semen analysis

32

what investigations can be done at the fertility clinical

pelvic ultrasounds
physical exam
further investigations
semen analysis repeat if required
tubal patency test

33

what is a HyCoSy and what is it used for

hysterosalpingo-contrast-sonography
small catheter though cervix then dye injected through

looks for patent tubes

34

what is laparoscopy used for

can assess tubal potency
diagnostic and therapautic to treat endometriosis
preferred for women with a higher tubal factor

35

what are the riss of laparotomy

risk of injury to bowel, bladder, ureter, thromboembolism

36

what is the difference between primary and secondary infertility

primary is couples who are struggling to conceive after 1 year with no previous pregnancies

secondary is couples who are struggling to convince after 1 year with at least one previous pregnancy i.e. were able to conceive before but not unable to

37

from most common to least common, what are the causes of primary infertility

ovulation problems
male - sperm problems
unexplained
tubal

38

from most common to least common, what are the causes of secondary infertility

tubal
ovulation problems
unexplained
male - sperm problems

39

what is polycystic ovary syndrome

set of symptoms due to elevated androgens in females

40

how can polycystic ovary syndrome be diagnosed

must beet 2 of the 3 criteria:
1. androgen excess (clinical hirsutism, biochemical testosterone)
2. infrequent periods (anovulation)
3. polycystic ovaries (seen on underground

41

what defines a polycystic ovary

more than 12 follicles in one ovary

42

what are the three groups of causes for ovulatory disorders

1. hypothalamic pituitary failure
2. hypo-pituitary-ovarian failure
3. ovarian failure

43

what is the treatment for ovulatory disorders

treat the underlying cause
weight loss/gain (BMI >18and <30)
ovulation induction

44

what are the three drugs used for ovulation induction

clomiphene (first line)
gonadotrophins
GnRH

45

what is clomiphene and how is it given

selective oestrogen receptor modulator
given 50mg-150mg day 2-6 of the cycle
if amenorrhoea - progestogen priming

NB does usually kept as low as possible to encourage only mono follicular development (higher % of conception)

46

how and why is clomiphene monitored

follicle scanning occurs in the 1st cycle

needed as 15% require a dose adjustment

47

what are the side effects of clomiphene

vasomotor
visual

48

how long can clomiphene be given for

6 cycles

49

when might gonadotrophin therapy be used

when no ovulation with clomiphene or ovulation but no pregnancy

50

how is gonadotrophin therapy given

FSH injection up to 3-6 cycles

51

what can be done if there is a tubal factor or endometriosis affecting fertility

some surgical or medical treatment for endometriosis and fibroids

consider IVF

52

what should a women with hydrasalpinges be offered before IVF and why

salpingectomy - fluid filled blocked tubes may cause further problems such as ectopic pregnancy

53

what treatment for infertility can males use

urologist appointment if appropriate
IVF/ICSI
intra-uterine insemination
surgery (vasectomy reversal, surgical sperm retrieval)
donor insemination

54

what is azoospermia

when semen contains no sperm

55

what are the types of azoospermia

testicular
- normogonadotrophic
- hypogonadotrophic
- hypergonadotrophic

post-testicular
- iatrogenic
- congenital
- infective

56

what are the investigations for azoospermia

history
examination
FSH, LH, testosterone, karyotype, PRL
CF screen

57

what is a possible treatment for azoospermia

surgical sperm retrieval
- micro-epididymal sperm aspiration
- testicular sperm extraction

58

what are some options for sexual problems that lead to infertility

psychosexual counselling - onward referral

artificial insemination - times at home, intra-uterine at clinic

59

what is the best course of action in treating unexplained infertility

IVF
(don't offer clomiphene)