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Infertility Flashcards

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1
Q

What is infertility

A

An inability to conceive after 12 months of regular intercourse (2-3 days)
Primary = if never conceived before

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2
Q

When should you investigate

A

After 1 year of trying

Earlier if known issue

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3
Q

What are known issues / reasons for early referral

A 
Age >35
Amenorrhoea / PCOS 
Previous pelvic surgery or on genitalia 
Previous STI - inc HIV / hep B 
Abnormal genital exam
Varicocele 
Systemic illness
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4
Q

When are you most fertile

A

Day 10-17 of cycle

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5
Q

What happens during your cycle

A

Luteal phase after ovulation = 14 days constant
Follicular = average 14
Ovulate on last day of follicle

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6
Q

When do you measure progesterone levels to see if ovulated

When do you ovulate

A

7 days prior to next period - usually day 21

14 days prior to next period

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7
Q

What can cause infertility

A 
Ovulatory
Tubal factor
Uterine / endometrial abnormality
Sexual problem
Azoospermia 
Unexplained
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8
Q

What causes ovulatory disorder

A 
Any cause 2 amenorrhoea
Exercise / weight loss
Hypogonadotrophic hypogonadism - hypothalamus / pituitary
PCOS
Ovarian failure
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9
Q

Wha causes tubal issue s

A 
PID
Previous ectopic
Previous surgery
Sterile 
Endometriosis
Fibroid compressing
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10
Q

What is unexplained

A

Test to see if eggs
Test to see if sperm
Can they meet and implant
If all fine= unexplained

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11
Q

What do you look in examination of the male

A 
BMI
Features of increased androgen
- Increased fat 
- Decreased hair
Abdo and inguinal exam
STI
Testicular size
Varicoccele
Vas deferens
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12
Q

What do you look for in female examination

A 
BMI
Fat and hair distribution 
Hirsutism
Galactorrhoea
Abdo and pelvic exam 
Acanthosis nigrican
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13
Q

What does hirsutism suggest

A

PCOS = most common
Androgen excess
Adrenal hyperplasia
Cushings

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14
Q

What does aconthosis nigrican suggest

A

Androgen excess

Insulin resistance

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15
Q

When does fertility decrease

A

Age
Chemo / RT
Can preserve embryos by freezing

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16
Q

What are 1st line investigations do you do in male and female

A

Computerised semen analysis

Mid literal progesterone or FSH / LH / testosterone if irregular to see if ovulating

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17
Q

What other female investigations are done prior to clinic

A 
BMI - if low anovulation? if high PCOS? 
Pelvic and breast exam
C+G
Rubella
TFT / prolactin 
Pelvic USS to look for structural
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18
Q

What do you do at clinic

A

Tubal potency test for blockage
HSG or HyCOSy - hysterosalpingography
Laparoscopy - Dx and can treat

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19
Q

How do you treat infertility / general advice

A 
Rx underlying condition e.g. PID 
Regular intercourse 2-3 days
Smoking and drinking advice
Aim BIM 
Folic acid 400mg
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20
Q

What do you do for ovulatory disorder

A

Clomifene = 1st line
Gonadotrophin
Metformin
FSH Injection

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21
Q

What is Clomifene

A

SERM
Triggers FSH and LH release regularly
Scan to see 1 dominant follicle

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22
Q

What are risks of clomifene

A

Multiple pregnancy
Ovarian cancer
Hyperstimulation
Can only use for 6 cycles

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23
Q

When do you use gonadotrophin

A

No ovulation after 6 cycles

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24
Q

What is metformin helpful in

Study These Flashcards
A

Underlying insulin resistance

May be used in addition to clomifene as increases effectiveness if resistant

25
What do you do for tubal factor
Surgery to remove or bypass tube - Risk of ectopic IVF
26
What is the only option for unexplained
IVF | NO ovarian stimulation
27
What is criteria for IVF
<42 BMI <30 Non smoker No children
28
What are the symptoms of ovarian hyper stimulation and how do you treat - More common with gonadotrophin / hCG Rx over clomifene
``` Abdo pain Bloating N+V Diarrhoea Hypotension ``` ``` If severe Ascites Oliguria Raised haematocrit VTE / ARDS = critical ``` Due to cystic enlargement so more at risk if have PCOS Fluid resus + VTE prophylaxis
29
What is azoospermia
No sperm in ejaculate
30
What are testicular causes of azoospermia
Hypogonadotrophic hypogonadism | Klienfelter syndrome
31
What does Klienflter present with
``` XXY Hypogonadism Low testosterone Small testicles Azoospermia ```
32
What are post-testicular causes
``` Radiation Congenital Infective - mumps. STI Absence of vas deferends Vasectomy ```
33
What puts you at risk of azoospermia
Smoking Exposure to heat and chemical Anabolic steroid
34
What investigations should be done
``` FSH / LH Testosterone Prolactin Karyotype CF screem Serum analysis ```
35
How do you treat Klienfelter
Testosterone injection
36
How do you treat azoospermia
``` Surgical sperm retrieval Intra-uterine insemination Reverse vasectomy Donor insemination IVF ```
37
What is PCOS
Syndrome of ovarian dysfunction Features of hyperandrogegism and PCO Causes 80% of fertility issues
38
What causes PCOS
Disorder LH production Insulin resistance so increased levels Increased androgen disrupts folliculogenesis RF - Obesity - FH - Ethnicity
39
What criteria used to Dx
Rotterdam | Require 2/3
40
What is Rotterdam criteria
PCO Anovulation or oligo Androgenic symptoms or elevated total or free serum testosterone (low SHBG)
41
What are symptoms of increased androgen
``` Hirsutism Acne Deep voice Enlarged clit Cushionoid Excess testosterone ``` Being on the COCP can hide these symptoms
42
What are other symptoms
``` Obesity Infertility Irregular cycle Can have heavy periods Plenty oestrogen but also high androgen Insulin resistance = DM (insulin promotes release of more androgens) CVS disease Aconthosis nigrican Chronic pelvic pain Depression ```
43
How do you Dx / investigate at GP
Basic obs, BM, urine dip Bloods - FBC, U+E, LFT, TFT, total testeroterone or sex hormone binding ``` Further Mid literal progesterone Hormonal profile Pelvic / transvaginal USS Check for impaired glucose tolerance Full infertility work up if want to conceive ```
44
When do you start on induction therapy
If all hormones are fine
45
What is hormonal profile
``` LH - raised LH / FSH ratio = raised FSH TSH Prolactin Testosterone = can be raised Oestrogen ```
46
What are general measures
Weight loss = 1st step in increasing fertility Exercise Stop smoking Monitor BP / lipid Screen for DM every 3-5 years Endometrial cancer risk - mineral coil or COCP to get regular bleed
47
What is step wise approach for fertility
``` Clomifene = 1st line Metfomrin = increase insulin resistance Gonaotropin - FSH or LH injection when follicle grown IVF = last resort ```
48
What does clomifene do
Binds to oestrogen receptor in pituitary | Trigger release of FSH and LH
49
What helps with androgen symptoms as anti-androgen / Hirstusim
``` Combined OCP Facial hair cream Metformin Cyproterone acetate / spironolactone = anti-androgen but must be on contraception Co-cyprindol - regulate menstruation ```
50
What do you give for endometrial protection as | anovulation increases risk / regulate menstruation
COCP - Want 3-4 bleeds Progestogen Mirena IUS
51
What are surgical options
Drilling
52
What are complications of PCOS
``` DM type 2 Obesity Higher CVD risk Higher VTE risk Endometrial hyperplasia OSA Infertility Miscarriage ```
53
What is PCO
>10 cyst Not technically cyst - follicles that start to develop then arrest Hypo-echoic or volume >12
54
What must you exclude
``` Other causes of hyperandrogegism Adrenal or ovarian tumour Adrenal hyperplasia Cushing Pituitary tumour ```
55
What is metformin useful for
Increasing effectiveness of clomifene Reduce gestational DM and miscarriage Reduce Hirsutism
56
What is risk of anovulation in PCOS
No CL so no progesterone No uterine bled and shed of lining Increased risk of endometrial hyperplasia Get irregular breakthrough bleed
57
What must you exclude if rapid onset hirsutism and very high testoerstoerne
testosterone secreting tumour
58
If abnormal prolactin
MRI head for prolactinoma

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