Management of infertility

Question 1

What is infertility?

Answer 1

Failure to achieve a clinical pregnancy despite 12 months of regular unprotected sex in couple who have never had a child before.

Question 2

Why does weight cause issues?

Answer 2

Increases rate of miscarriage by 2/3x
Increased erectile dysfunction
Decreases success rate with fertility treatment.
Decreases fertility and sperm motility

Question 3

What vaccine is given prior to attempts at conception?

Answer 3

MMR vaccine, must have been on contraception for 4 weeks prior.

Question 4

Why is the MMR vaccine given?

Answer 4

As rubella causes serious issues in the foetus.

Question 5

What does rubella increase the risk of in pregnancy?

Answer 5

Microcephaly
Patent ductus arteriousus
Cataracts
Rash

Question 6

What types of ovulary disorders are there?

Answer 6

Type I
Type II
Type III
Other

Question 7

What is a type I ovulatory disorder?

Answer 7

Hypothalamic

Question 8

How does a type I hypothalamic disorder present?

Answer 8

Low FSH LH Oestrogen
Normal Prolactin
-ve Progesteron challenge
Amenorrhea

Question 9

What is a type II ovulatory disorder?

Answer 9

Hypothalamic Pituitary dysfunction

Question 10

What is a type III ovulatory disorder?

Answer 10

Ovarian failure

Question 11

What is the mainstay of treatment in a type III ovulatory disorder?

Answer 11

Combined contraceptive pill
HRT
Egg preservation
Counselling

Question 12

What are the other causes of infertility?

Answer 12

Hyperprolactinaemia

Hypothyroidism

Question 13

What is the main type I ovulatory disorder?

Answer 13

Hypogonadotrophic hypogonadism

Failure to release adequate GnRH from hypothalamus

Question 14

What are some causes of type I ovulatory disorders ?

Answer 14

Stress
Excessive exercise 
Anorexia
Pituitary tumour
Head trauma
Steroid and opiates

Question 15

What must be done before treatment of a type I ovulatory disorder?

Answer 15

Stabilise weight
Reduce alcohol and smoking
Folic acid 
Rubella vaccine
Semen analysis

Question 16

What two options are there for the treatment of a type 1 ovulatory disorder?

Answer 16

Pulsatile GnRH

Gonadotrophin injections

Question 17

What is the GnRH pump?

Answer 17

Induces ovulation by inducing the correct levels of LH and FSH.

Question 18

Are there any risks associated with the pulsatile GnRH pump?

Answer 18

Low multiple pregnancy risk

Question 19

What are the gonadotrophin injections?

Answer 19

LH and FSH administered daily

Question 20

Are there any risks associated with the gonadotrophin injections?

Answer 20

High multiple pregnancy risk

Question 21

What do both the gonadotropin injections and the pulsatile GnRH pump require?

Answer 21

USS monitoring of the follicles.

Question 22

What is the most common type II ovulatory disorder?

Answer 22

Polycystic ovarian syndrome

PCOS

Question 23

How does PCOS present biochemically?

Answer 23

Normal gonadotrophins / excess LH
Normal oestrogen
Increased free testosterone

Question 24

How does PCOS present clinically?

Answer 24

Oligo/Amenorrhea

Insulin resistance

Question 25

What is the mainstay of treatment for PCOS?

Answer 25

Clomifene + metformin for insulin resistance and improved sensitivity +Gonadotrophin injections

Question 26

What are the risks associated with PCOS treatment?

Answer 26

Multiple pregnancy risk

Question 27

What are the three hallmarks associated with PCOS?

Answer 27

Hyperandrogenism Hirsutism Cystic ovaries on USS- Pearl necklace

Question 28

What are some of the risks associated with multiple pregnancy to the mother?

Answer 28

``` Hyperemesis Anaemia Pre eclampsia Gestational diabetes Post partum haemorrhage Post natal depression ```

Question 29

What are some of the risks associated with multiple pregnancy to the foetus's?

Answer 29

Low birth weight Increased miscarriage Increased risk of disability Increased risk of perinatal death

Question 30

What is pre eclampsia?

Answer 30

The onset of hypertension during pregnancy resulting in seizures low platelet counts and oedema.

Question 31

What is twin twin transfusion syndrome?

Answer 31

Unbalanced vascular communication resulting in one receiving more blood and nutrients than the other. Significant cause of perinatal mortality. 80-100% fatality

Question 32

What is the treatment for twin twin transfusion syndrome?

Answer 32

Laser division of the vessels

Question 33

What are the risks associated with prematurity?

Answer 33

Increased risk of respiratory distress syndrome Reduced IQ Increased risk of ADHD speech issues etc

Question 34

What is premature ovarian failure?

Answer 34

Halt of periods before 40

Question 35

What are some causes of premature ovarian failure?

Answer 35

Turners Idiopathic Chemotherapy Radiotherapy

Question 36

What are some clinical signs of premature ovarian failure?

Answer 36

Flushes Night sweats Atrophic vaginitis

Question 37

Hoe does premature ovarian failure present biochemically?

Answer 37

High FSH and LH | Low oestrogen

Question 38

What are some infective causes of tubal diseases?

Answer 38

Pelvis inflammatory - STI TB | Trans peritoneal appendicitis

Question 39

What are some non infective causes of tubal damage?

Answer 39

``` Endometriosis Surgical Fibrosis Fibroids Polyps ```

Question 40

What are some signs of a pelvis infection?

Answer 40

``` Abdominal pain Vaginal discharge Menorrhagea Infertility Ectopic pregnancy ```

Question 41

What is endometriosis?

Answer 41

Endometrial glands located outside the uterine cavity

Question 42

How does endometriosis present?

Answer 42

``` Dysmenorrhea Painful defecation Chronic pelvic pain Chocolate cysts on ovary Infertility ```

Question 43

What are the types of fibroids?

Answer 43

Pedunculated Subserous Submucous Intramural

Question 44

Of the different types of fibroids which ones are generally operated on?

Answer 44

Submucos and intramural

Question 45

What surgical treatment can be used for PCOS

Answer 45

Laparascopic Ovarian Diathermy | Literally drilling holes in the ovaries

Question 46

What are the risks associated with laparoscopic ovarian diathermy?

Answer 46

Risk of ovarian destruction or adhesions

Question 47

What are the types of male infertility?

Answer 47

Post Testicular Testicular Pre Testicular Non ob

Question 48

Name some causes of post testicular infertility?

Answer 48

CF Vasectomy Duct Obstruction Accessory gland infection

Question 49

How does post testicular infertility present biochemically?

Answer 49

Testosterone FSH and LH levels are all normal

Question 50

What is the management of someone with post testicular infertility usually?

Answer 50

USS guided surgical removal of sperm

Question 51

Name some causes of testicular infertility?

Answer 51

``` Klinefelters immotile cilia syndrome Heat Irradiation Drugs Chemotherapy Testicular torsion ```

Question 52

How does testicular infertility clinically present?

Answer 52

Low sperm count

Question 53

What is the main cause of pre testicular infertility?

Answer 53

Hypogonadism

Question 54

How does pre testicular infertility present both clinically and biochemically?

Answer 54

Low FSH LH and Testosterone | Erectile dysfunction

Question 55

What are some common causes of a non obstructive infertility?

Answer 55

Chemotherapy Radiation Klinefelters

Question 56

How does non obstructive infertility present biochemically ?

Answer 56

FSH and LH is high | Testosterone is Low

Question 57

How does non obstructive infertility present clinically?

Answer 57

Low testicular volume Reduced secondary sexual characteristics Vas deferens is present

Question 58

List some factors that increase infertility

Answer 58

``` Precocious pregnancy Smoking >2 cups of coffee Recreational drugs BMI over 30 Over 30 ```

Question 59

What is anovulatory infertility?

Answer 59

Where the ovaries don't release an oocyte during the menstrual cycle.

Question 60

What are the physiological causes of anovulatory infertility?

Answer 60

Pre puberty Pregnancy Lactation Menopause

Question 61

What are some gynaecological causes of anovulatory infertility?

Answer 61

Hypothalamic- anorexia bulimia excessive exercise Endocrine- Hyperprolactinaemia tumours Sheehan Ovarian- PCOS premature ovarian failure

Question 62

List some other causes of anovulatory infertility?

Answer 62

Systematic- chronic renal failure | Endocrine- testosterone secreting tumours

Question 63

What is Sheehans syndrome?

Answer 63

Hypoxic damage to the pituitary during childbirth caused by severe haemorrhage, leading to the failure of the pituitary gland.