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Flashcards in Management of Infertility Deck (59):
1

What is infertility?

Failure to conceive despite regular unprotected sex over 12 months in absence of known reproductive pathology

2

Primary vs. secondary infertility?

Primary: couple never conceived
Secondary: couple previously conceived

3

Which infection associated with infertility?

Chlamydia

4

Test for chlamydia?

Endocervical swab

5

How do you check for rubella immunity?

Bloods

6

When do you check progesterone level when investigating infertility?

MIDLUTEAL PHASE
(day 21 of 28 day cycle, or 7 days prior to expected period in prolonged cycle)
MUST TAKE 2 SAMPLES

7

Progesterone over which level (nmol/l) is suggestive of ovulation?

>30nmol/l

8

Rash at birth
Low birth weight
Small head size
Heart abnormalities
Visual problems
Bulging fontanelles

Rubella syndrome

9

Microcephaly
Cataracts
Patent ductus arteriosus

Rubella syndrome

10

Short term complications of pelvic inflammatory disease (e.g. chalmydia)

Tubo-ovarian abscess
Peritonitis
Fitz-High-Curtis syndrome

11

Long term consequences of pelvic inflammatory disease?

Chronic pelvic pain
Infertility
Ectopic pregnancy

12

Fitz-Hugh-Curtis Syndrome?

upper quadrant pain (inflammation of liver capsule or diaphragm from spread of infection from pelvic inflammatory disease)

13

What is a hydrosalpinx?

Distally blocked fallopian tube filled with serous/clear fluid

14

Group I ovulatory disorders?

Hypothalamic
(amenorrhea-includes stress, excessive exercise, anorexia, Kallman's syndrome, isolated gonadotropin deficiency)

15

Findings of group I ovulatory disorders

Low FSH, estrogen, normal prolactin, negative progesterone challenge

16

Group II hypothalamic pituitary dysfunction

Normogonadotrophic-normoestrogenic anovulation

e.g. PCOS

17

Group III ovulatory disorders

Ovarian failure
-high gonadotrophins with low estrogens

18

Which type of ovulatory disorder is PCOS?

Type II (hypothalamic-pituitary dysfunction)

19

Hysterosalpingogram

x-ray that examines the uterus and the fallopian tubes and the surrounding area

20

Commonest cause of anovulatory infertility?

Polycystic ovary syndrome

21

Increased ovarian volume?

>10ml

22

How many follicles in PCOS?

More than 12 (between 2-8mm)

23

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 estradiol
-low progesterone
-normal or mildly elevated prolactin
-raised testosterone/FAI/A4

24

LH/FSH ratio in PCOS?

LH/FSH ratio >2

25

Serum LH in PCOS?

Elevated serum LH (>10IU/L)

26

Estradiol in PCOS?

Normal

27

Progesterone in PCOS?

Low

28

Testosterone in PCOS?

Raised

29

Clomifene citrate
Tamoxifen

Antioestrogens

30

Letrozole

Aromatase inhibitors

31

Ovulation induction: first line of treatment

Antioestrogens: clomifene citrate
Tamoxifen
Aromatase inhibitors: letrozole

32

How do you clomifene citrate (anti-oestrogens)

Monitor with tracking scan and serum progesterone

33

When do you give clomifene citrate?

Day 2- day 6 for 5 days

34

When do you give tamoxifen?

Day 2-6 for five days

35

Adverse effect of tamoxifen?

Estrogenic effect on endometrium

36

First line treatment for PCOS?

Anti-oestrogens: Clomifene citrate/tamoxifen
Aromatase inhibitors: Letrozole

37

Second line treatment for PCOS?

1) clomifene citrate + metformin
2) Gonadotropin therapy: daily injections (FHS and LH etc)
3) Laparoscopic ovarian diathermy

38

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

39

Most common cause of male infertility?

Idiopathic

40

Vasectomy, infection (e.g. chlamydia/gonorrhoea), congenital absence of vas deferens (e,.g. cystic fibrosis)

Obstructive causes of male infertility

41

Undescended testis, orchitis (e.g. mumps), torion/trauma, chromosomal (e.g. Klinefelter's syndrome) Kartagener syndrome, Y chromsome micro deletions

Non-obstructive causes

42

Hormonal causes of infertility?

Hypogonadotrophic hypogonadism
Hypothyroidism
Hyperprolactinemia

43

PESA

percutaneous epididymal sperm aspiration
-you can also do percutaneous testicular sperm aspiration

(both you put a needle in to take out the sperm)

44

MESA

Microsurgical epididymal sperm aspiration

45

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

46

Salpingitis isthmica nodosa?

Diverticulosis of the fallopian tube = nodular thickening of the narrow part of the uterine tube due to inflammation

47

Fibroids

Non-cancerous growths in the uterus

48

Treatment of tubal disease

Tubal surgery
Selective salpingiogrpahy and catheterisation
In-vitro fertilisation

49

How many times should you have sex?

2-3 times a week

50

How much alcohol should women drink?

Limit to 4 units per week

51

Optimal weight for fertility?

19-29

52

Folic acid for fertility?

0.4mg/day preconception till 12 weeks gestation

53

When would you do hysteroscopy?

Only performed in cases where suspected or known endometrial pathology: i.e. uterine septum, adhesions, polyp

54

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

55

What is endometriosis?

Presence of endometrial glands outside the uterine cavity

56

Symptoms of endometriosis

dysmenorrhoea, dysparenuia, menorrhagia, painful defaecation, chronic pelvic pain (severity of pain may be disproportionate to extent of disease)

57

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)

58

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)
In-Vitro Fertilisation

59

Treatment of premature menopause

Counselling
Fertility: oocyte donation
Prevention osteoporosis (OCP, HRT
Cryopreservation of ovarian tissue (prior to radiotherapy or chemotherapy)