Flashcards in Management of Infertility Deck (59)
What is infertility?
Failure to conceive despite regular unprotected sex over 12 months in absence of known reproductive pathology
Primary vs. secondary infertility?
Primary: couple never conceived
Secondary: couple previously conceived
Which infection associated with infertility?
Test for chlamydia?
How do you check for rubella immunity?
When do you check progesterone level when investigating infertility?
(day 21 of 28 day cycle, or 7 days prior to expected period in prolonged cycle)
MUST TAKE 2 SAMPLES
Progesterone over which level (nmol/l) is suggestive of ovulation?
Rash at birth
Low birth weight
Small head size
Patent ductus arteriosus
Short term complications of pelvic inflammatory disease (e.g. chalmydia)
Long term consequences of pelvic inflammatory disease?
Chronic pelvic pain
upper quadrant pain (inflammation of liver capsule or diaphragm from spread of infection from pelvic inflammatory disease)
What is a hydrosalpinx?
Distally blocked fallopian tube filled with serous/clear fluid
Group I ovulatory disorders?
(amenorrhea-includes stress, excessive exercise, anorexia, Kallman's syndrome, isolated gonadotropin deficiency)
Findings of group I ovulatory disorders
Low FSH, estrogen, normal prolactin, negative progesterone challenge
Group II hypothalamic pituitary dysfunction
Group III ovulatory disorders
-high gonadotrophins with low estrogens
Which type of ovulatory disorder is PCOS?
Type II (hypothalamic-pituitary dysfunction)
x-ray that examines the uterus and the fallopian tubes and the surrounding area
Commonest cause of anovulatory infertility?
Polycystic ovary syndrome
Increased ovarian volume?
How many follicles in PCOS?
More than 12 (between 2-8mm)
Diagnosis of PCOS (Rotterdam criteria)
-Irregular menstrual cycle, hirsutism, acne, subfertility, alopecia, obesity, acanthosis nigricans
Biochemical: day 2 - day 5
-elevated serum LH (>10IU/L)
-LH/FSH ratio >2
-normal or mildly elevated prolactin
LH/FSH ratio in PCOS?
LH/FSH ratio >2
Serum LH in PCOS?
Elevated serum LH (>10IU/L)
Estradiol in PCOS?
Progesterone in PCOS?
Testosterone in PCOS?
Ovulation induction: first line of treatment
Antioestrogens: clomifene citrate
Aromatase inhibitors: letrozole
How do you clomifene citrate (anti-oestrogens)
Monitor with tracking scan and serum progesterone
When do you give clomifene citrate?
Day 2- day 6 for 5 days
When do you give tamoxifen?
Day 2-6 for five days
Adverse effect of tamoxifen?
Estrogenic effect on endometrium
First line treatment for PCOS?
Anti-oestrogens: Clomifene citrate/tamoxifen
Aromatase inhibitors: Letrozole
Second line treatment for PCOS?
1) clomifene citrate + metformin
2) Gonadotropin therapy: daily injections (FHS and LH etc)
3) Laparoscopic ovarian diathermy
Investigating semen in men?
Semen analysis: twice over six weeks apart
-If abnormal, do an endocrine profile
-if SEVERELY abnormal --> do endocrine profile AND chromosome analysis and screen for cystic fibrosis, testicular biopsy
Most common cause of male infertility?
Vasectomy, infection (e.g. chlamydia/gonorrhoea), congenital absence of vas deferens (e,.g. cystic fibrosis)
Obstructive causes of male infertility
Undescended testis, orchitis (e.g. mumps), torion/trauma, chromosomal (e.g. Klinefelter's syndrome) Kartagener syndrome, Y chromsome micro deletions
Hormonal causes of infertility?
percutaneous epididymal sperm aspiration
-you can also do percutaneous testicular sperm aspiration
(both you put a needle in to take out the sperm)
Microsurgical epididymal sperm aspiration
When do you do hysterosalpingogram/laparoscopy & dye?
In the first 10 days of cycle
-be careful in obesoty, previous pelvic surgery and Crohn's disease
Salpingitis isthmica nodosa?
Diverticulosis of the fallopian tube = nodular thickening of the narrow part of the uterine tube due to inflammation
Non-cancerous growths in the uterus
Treatment of tubal disease
Selective salpingiogrpahy and catheterisation
How many times should you have sex?
2-3 times a week
How much alcohol should women drink?
Limit to 4 units per week
Optimal weight for fertility?
Folic acid for fertility?
0.4mg/day preconception till 12 weeks gestation
When would you do hysteroscopy?
Only performed in cases where suspected or known endometrial pathology: i.e. uterine septum, adhesions, polyp
When would you do pelvic ultrasound?
perform when abnormality on pelvic examination: e.g. enlarged uterus/adnexal mass
when required from other investigations: e.g. possible polyp seen at HSG
What is endometriosis?
Presence of endometrial glands outside the uterine cavity
Symptoms of endometriosis
dysmenorrhoea, dysparenuia, menorrhagia, painful defaecation, chronic pelvic pain (severity of pain may be disproportionate to extent of disease)
Why does endometriosis affect fertility?
Reasons impaired infertility: anatomical damage (tubo-ovarian adhesions), dyspareunia, altered peritoneum environment (cytotoxic factors: impaired ovulation, lower embryo quality and impaired implantation)
Treatment for endometriosis?
Medical: combined oral contraceptive pill, progesterones (medroxyprogesterone acetate), GnRH agonists (zoladex +/- add back HRT)
Surgical : Laparoscopic ablation/resection and adhesiolysis of mild disease
Radical resection of severe endometriosis
Drainage and ablation cyst base for endometriomas (consider prior to IVF)