Module 14 - Subfertility Flashcards
1
Q
Sperm analysis. What is normal semen volume?
A
Semen volume: Greater than or equal to 1.5 ml
2
Q
Sperm analysis. What is normal pH?
A
pH: Greater than or equal to 7.2
3
Q
Sperm analysis. What is normal sperm concentration?
A
Sperm concentration: Greater than or equal to 15 million spermatozoa per ml
4
Q
Sperm analysis. What is normal sperm number?
A
Total sperm number: 39 million spermatozoa per ejaculate or more
5
Q
Sperm analysis. What is normal motility?
A
total motility (% of progressive motility and non-progressive motility): 40% or more motile or 32% or more with progressive motility
6
Q
Sperm analysis. What is normal vitality?
A
Vitality: 58% or more live spermatozoa
7
Q
Sperm analysis. What is normal morphology?
A
Sperm morphology (percentage of normal forms): 4% or more
8
Q
When do you repeat sperm analysis if it is abnormal?
A
If sperm count abnormal repeat in 3 months - to allow time for another cycle of spermatozoa to form
OR
Repeat sperm analysis ASAP if azoospermia or severe oligozoospermia i.e. <5 million sperm/ml detected
9
Q
Which OHSS can receive outpatient care? How often do they need to be reviewed?
A
Mild OHSS
Moderate OHSS
Severe OHSS - in selective cases. They will need LMWH
They need to receive appropriate counselling and information regarding fluid monitoring
Review the patient every 2-3 days
10
Q
What are the criteria for hospital admission of OHSS?
A
1) Unable to control PAIN
2) Unable to maintain adequate fluid intake, due to nausea/vomiting
3) Worsening OHSS, despite outpatient management
4) Critical OHSS
5) Unable to attend for regular outpatient follow-up
Critical OHSS = ICU input
11
Q
Can you use diuretics in OHSS?
A
Only use diuretics if OLIGURIC - despite adequate fluid replacement and ascitic drainage
Get input from the MDT, i.e. ICU
12
Q
Which fluids should be given to women with OHSS who had had large volumes of ascitic fluid drained by paracentesis?
A
i.v. colloids
Human Albumin Solution 25% (HAS) - used as a plasma volume expander. Doses of 50-100g given over 4 hours every 4-12 hours
13
Q
Which increased risks do pregnancies with OHSS have?
A
Increased risks of:
1) Pre-eclampsia
2) Pre-term delivery
14
Q
What is the pathophysiology of OHSS? Which features are caused?
A
Exposure of hyperstimulated ovaries to hCG leads to over-expression of pro-inflammatory mediators, i.e. VEGF (Vascular Endothelial Growth Factor) and other cytokines
Causes:
1) Increased vascular permeability (intravascular fluid depletion, ascites, pleural effusion, pericardial effusion)
2) Increased pro-thrombosis (PE, DVT)
3) Decreased serum osmolality
4) Hyponatraemia
15
Q
What is the incidence of OHSS?
A
Mild OHSS - 1/3 of IVF cycles
Moderate - Severe OHSS - 3-8%
Difficult to know the true incidence of OHSS as there is no mandatory reporting of mild and moderate cases and there is no internationally agreed classification system
OHSS is rare following ovarian stimulation with Clomifene (SERM)
OHSS can very rarely occur with spontaneous conception
16
Q
What are the risk factors for OHSS?
A
1) Previous OHSS
2) PCOS
3) Increased AFC (Antral Follicle Count)
4) Increased AMH
17
Q
What are the definitions of early and late OHSS?
A
Early OHSS - <7 days from the hCG trigger injection used to promote final follicular maturation prior to egg retrieval
The ovarian response is exaggerated - women have excessive abdominal pain and distension
Late OHSS - ≥10 days from the hCG trigger injection
Usually the result of endogenous hCG from an early pregnancy
Trigger injection response is usually unremarkable
Usually more prolonged and severe than early OHSS
18
Q
What diagnostic features are characteristic of OHSS?
A
Increased haematocrit + Decreased serum osmolality + Hyponatraemia = OHSS
19
Q
What are the differential diagnoses of OHSS?
A
- Appendicitis
- Ovarian cyst accident
- Ectopic pregnancy
- Bowel perforation
- PID
- Pelvic abscess
20
Q
What are the categories of OHSS?
A
Mild OHSS:
- Abdominal bloating
- Mild abdominal pain
- Ovary size <8cm
Moderate OHSS:
- Moderate abdominal pain
- US evidence of ascites
- Nausea +/- vomiting
- Ovary size 8-12cm
Severe OHSS:
- Clinical ascites +/- hydrothorax
- Na+ <135
- K+ >5
- Oliguria (UO <300ml/day or <30ml/hr)
- Hypo-osmolality <282
- Haematocrit >0.45
- Decreased album <35
- Ovary size >12cm
Critical OHSS:
- Tense ascites/large hydrothorax
- ARDS
- VTE
- Haematocrit >0.55
- Oliguria/anuria
- WCC >25
21
Q
What are the life-threatening complications of OHSS?
A
1) Renal failure
2) ARDS
3) VTE
4) Haemorrhage from ovarian rupture
22
Q
What is the recovery period like for OHSS?
A
In most women OHSS is self-limiting and resolves over 7-10 days
If the woman becomes pregnant then the endogenous hCG usually makes it worse
If she doesn’t become pregnant then recovery occurs by the time she has a withdrawal bleed
23
Q
What do you need to assess during a woman with OHSS daily review?
A
1) Abdominal girth - ensure it’s not increasing
2) Body weight - ensure it’s not increasing
3) Fluid monitoring - ensure she’s not oliguric and passing >300ml/day or >30ml/hr
4) Bloods - FBC, U&Es, LFTs, osmolality, CRP
5) LMWH
24
Q
When do you need to seek help from ICU/MDT in OHSS?
A
If persistent haemoconcentration and oliguria despite adequate fluid hydration
They may prescribe diuretics to improve urine output
25
What is the maximum amount of fluid that can be drained by paracentesis in women with OHSS?
There is no set limit of the amount of fluid that can be drained by paracentesis
Women with OHSS are typically younger and able to tolerate removal of larger quantities of fluid/ascites
If you remove a large volume of ascites - give i.v. colloids for replacement
Early drainage of ascites to decrease intra-abdominal pressure in patients with moderate-severe OHSS may prevent progression of disease and lower the risk of severe complications
26
What is the incidence of VTE in OHSS?
0.7 - 10%
27
How long do you give VTE prophylaxis for in severe OHSS?
At least until the end of the 1st trimester
28
Where does thrombosis frequently affect in OHSS? How do they present?
Thrombosis in OHSS typically affects the upper limbs and arterial system
Suspect it if a patient presents with: dizziness, neck pain and loss of vision
29
Which form of OHSS has a higher miscarriage rate? Early or Late OHSS?
Early OHSS
30
What ovarian complications can arise from OHSS?
1) Ovarian torsion
2) Ovarian rupture
OHSS increases the size and vascularity of ovaries, especially if pregnant
31
In IVF pregnancies is there an increased risk of miscarriage with OHSS?
No
There is no increased miscarriage rate with OHSS vs. non-OHSS IVF
32
What proportion of the general population will conceive within 1 year?
80% of the general population will conceive within one year if:
- Women is <40 years old
- They do not use contraception and have regular sexual intercourse
33
What proportion of the general population will conceive within 2 years?
Of the 20% of the general population who do not conceive within the 1st year, half of them (10%) will conceive in the second year (90%).
Therefore, 90% of the general population will conceive within 2 years if the woman is <40 years, are not on contraception and have regular SI
34
What is the definition of infertility?
A woman of reproductive age who has not conceived after 1 year of unprotected vaginal sex
35
What is the incidence of infertility in the UK?
Infertility affects 1 in 7 heterosexual couples in the UK
36
What are the success rates with artificial insemination?
- >50% of women <40 years will conceive with 6 cycles of intrauterine insemination (IUI)
- 58% of women <30 years will conceive after 6 cycles of IUI
- Of those who do't conceive with the first 6 cycles, half will conceive with a further 6 cycles
37
What is the recommended frequency of vaginal sexual intercourse to optimise the chance of pregnancy?
2-3x per week
If you have sex 3x per week - it increases your chance of pregnancy by 50%
38
What are the recommendations for alcohol in couples with subfertility trying to conceive?
Women - decrease drinking to 1-2 units/week to decrease the harmful effects to the fetus (which may not be known)
Also avoid being drunk (episodes of intoxication)
Men - drinking Department of Health's alcohol intake recommendation (<14 units/week spread over 3 days or more) shouldn't affect semen quality
However, excessive alcohol decreases semen quality
39
What are the recommendations for smoking in couples with subfertility trying to conceive?
Women - smoking likely decreases fertility
Offer smoking cessation programmes
passive smoking likely decreases fertility
If patient referred for IVF and is smoking, you discharge back to GP. Patient needs to complete smoking cessation for 3/12
Men - smoking decreases semen quality
Stopping smoking will improve overall general health
40
What are the recommendations for caffeine in couples with subfertility trying to conceive?
No consistent evidence that consumption of caffeinated beverages (coffee, tea, colas) affects fertility
Caffeine may be linked to IUGR
41
What is the effect of obesity on fertility?
BMI >30 - can take longer to conceive (for both men and women). Won't receive NHS-funded IVF
Increased miscarriage rates by 50%
Adipose tissue stores hormones (oestrogen) - so decreased ovarian response
If BMI >30 + anovulation - weight loss will likely increase their chance of conception
Women participating in group programmes focusing on diet and exercise lead to more pregnancies than weight loss advice alone
BMI <30 in men - increased semen quality
42
What is the effect of low body weight on fertility?
Women with BMI <19 with oligomenorrhoea or amenorrhoea - advised that increasing body weight may improve their fertility
BMI <19 - don't offer IVF
43
What is the effect of tight underwear on fertility?
Tight underwear = increased scrotal temp = decreased semen quality
Uncertain whether wearing loose-fitting underwear improves fertility
44
What dose of folic acid is recommended in women with subfertility?
3 months prior to conception and up to 12/40 gestation women with subfertility should take Folic acid 400 micrograms OD
Take 5mg OD if:
- Diabetes
- WWE on AEDs
- Previous history of NTD
45
When should women who have been trying to conceive be referred/offered further clinical assessment and investigation?
GPs investigate for infertility in women of reproductive age who have been trying to conceive for ≥1 year
Women who have received 6 cycles of artificial insemination (IUI or ICI) with partner or donor sperm and have not conceived
46
Which women do you offer earlier referral for IVF for?
1) >36 years old
2) Known cause of infertility or a history of predisposing factors for infertility
3) Having Chemotherapy
47
Which markers are used to predict the likely ovarian response to gonadotrophin stimulation in IVF?
Use any one of the following:
1) Antral Follicle Count - how many follicles seen on scan. Can fluctuate month-to-month
low response - ≤4
high response - >16
2) AMH
low response - ≤5.4 - do not offer IVF
high response - ≥25 - risk of OHSS
3) FSH
low response - >8.9 - do not offer IVF
high response - <4
48
What test(s) do you use to confirm ovulation?
Mid-cycle serum progesterone - perform this on Day 21 (mid-luteal phase)
If progesterone >30 = ovulation
If you have prolonged irregular cycles then perform a mid-cycle serum progesterone, day 2-3 FSH and LH
i.e. for a 35 day cycle perform progesterone at Day 28 (as ovulation is always 14 days before menses)
Basal body temp - is not a reliable method to confirm ovulation, therefore is not recommended
49
Which tests are not routinely performed as part of investigation for subfertility?
1) Prolactin - perform if: ovulatory disorder (oligomenorrhoea), galactorrhoea or pituitary tumour
2) Endometrial biopsy - not needed to evaluate luteal phase as there is no evidence that medical treatment of luteal phase defect improves pregnancy rates
50
When do you perform HSG (Hysterosalpingography)?
You perform HSG after 3 failed IVF cycles
To test the patency of the fallopian tubes
51
What are the contraindications to HSG to screen for tubal occlusion?
1) PID
2) STI
3) Previous Ectopic pregnancy
4) Endometriosis
In these circumstances do laparoscopy + dye test so other pelvic pathology can be assessed at the same time
52
When is the risk of HIV transmission from a HIV positive man to a woman negligible?
If:
1) The man is fully compliant with HAART (Highly Active Anti-Retroviral Treatment)
2) Plasma Viral load <50 copies/ml for >6 months
3) No other infections present
4) Unprotected SI is limited to the time of ovulation
If these criteria are met then sperm washing may not reduce the risk of transmission and may actually reduce the likelihood of conception - however, if they still want it they can have it
Women need not use PrEP (Pre-Exposure Prophylaxis) if all criteria are met
53
When do you offer sperm washing for a couple where the man is HIV +ve?
1) If the man is not fully compliant with HAART
2) If the plasma viral load is >50 copies/ml
Sperm washing decreases but doesn't eliminate the risk of HIV transmission
54
In subfertility couples if the man is Hep B+ what is the management for the woman?
Offer the Hep B vaccine
Don't offer sperm washing (unless he is HIV +ve)
55
In subfertility couples if the man is Hep C+ what is the management for them?
If the man is Hep C +ve there is a low risk of transmission through unprotected vaginal intercourse
They should aim to have it eradicated prior to conception - so seek their Hepatologist
56
What infections should couples undergoing IVF be screened for?
1) HIV
2) Hep B
3) Hep C
4) Rubella - if woman is susceptible to Rubella then give the vaccine and advise not to conceive for at least 1 month (it is a live vaccine)
5) Chlamydia - test before any instrumentation of the uterus. Prophylactically treat if no test available. If positive to see Sexual Health clinic for contacting tracing and treatment
57
What is the management of men with subfertility who have been determined to have hypogonadotrophic hypogonadism?
Gonadaotrophin drugs - these are effective in improving fertility
58
What is the management of men with subfertility due to obstructive azoospermia?
Surgical correction
59
What is the management of men with subfertility due to varicocele?
Refer to Urologist
60
What is the management of men with subfertility due to retrograde ejaculation?
Ephedrine
Spin sperm and then freeze
61
What is the WHO classification of Ovulation disorders?
Group 1) Hypogonadotrophic Hypogonadism:
- Kallman syndrome - decreased neurone development of the hypothalamus
- Sheehan syndrome - pituitary ischaemia secondary to PPH
- Stress
- Anorexia nervosa
- Pituitary tumour
- Excessive exercise
Low/normal FSH
Low Oestradiol
Group 2) Hypothalamic - Pituitary - Ovarian dysfunction
- Mainly PCOS
Normal Oestradiol
Normal FSH
High AMH
High LH:FSH ratio
Hyperadrogenism - High Free Testosterone, Low SHBG
Group 3) Ovarian failure
- Chemotherapy
- Radiotherapy
- Genetic
- Autoimmune
- Turner's Syndrome
- Primary ovarian insufficiency
62
What is the treatment/management of WHO Group I Ovulation Disorders?
1) If underweight (BMI <19) - to increase BMI >19
2) If vigorous exercise - to reduce levels
3) Give pulsatile GnRH or GnRH with LH activity (FSH + LH) to induce ovulation
63
What is the treatment/management of WHO Group II Ovulation Disorders?
If Group II + BMI >30 - weight loss can cause ovulation, improve their response to ovulation induction agents and improve overall pregnancy outcomes
1st line:
- Clomifene citrate (SERM)
- Metformin
- Clomifene + Metformin
If taking Clomifene:
- US within at least the 1st cycle - to ensure taking the lowest effective dose to minimise the risk of multiple pregnancy
- Don't continue for >6 months - as increased risk of OHSS
- 40% pregnancy rate
If taking Metformin warn of SE: nausea, vomiting, GI symptoms
2nd line (If resistant to Clomifene):
- Clomifene + Metformin
- Laparoscopic ovarian drilling
- Gonadotrophins
If woman taking Gonadotrophins don't give GnRH agonist also as you increase the risk of OHSS
64
What is the management of subfertile women with proximal tube occlusion/obstruction?
Straight to IVF
Previously used to be Selective salpingography + tubal catheterisation
OR
Hysteroscopic tubal cannulation
65
What is the management of subfertile women with hydrosalpinx?
Laparoscopic Salpingectomy
Laparoscopy is the preferred method of surgery
Perform prior to IVF treatment as it improves the chance of a live birth
66
What is the management of subfertile women with endometriosis?
If endometrioma >4cm
Laparoscopic cystectomy increases pregnancy rates
67
What is the management of subfertile women with amenorrhoea, found to have Asherman's syndrome?
Hysteroscopic adhesiolysis
It is likely to restore menstruation and improve the chance of pregnancy
68
What is the management of unexplained infertility?
1) Don't give women with unexplained infertility: Clomifene, Anastrozole or Letrozole (oral ovulation agents)
2) Clomifene citrate alone does not improve the chances of pregnancy or a live birth in women with unexplained infertility
3) Women with unexplained infertility should try to conceive for a total of 2 years (including up to 1 year before their fertility investigations) before they are referred to IVF/ICSI
69
What are the indications for IUI (Intrauterine Insemination)?
1) People who are unable or who would find it difficult to have vaginal sexual intercourse, i.e. physical disability or psychosexual problems, i.e. dyspareunia. Whom are using partner or donor sperm
2) Women with male partners who are HIV +ve and need sperm washing
3) Same-sex relationships
70
How many cycles of IUI (intrauterine insemination) do you offer patients?
Initially offer 6 cycles with partner or donor sperm
If after 6 cycles (with evidence of normal semen analysis, normal ovulation and normal tubal patency) then offer another 6 cycles of unstimulated IUI before IVF is considered
Same-sex couples - offer 3 cycles. If unsuccessful then offer IVF
71
What is the definition of mild male factor inferility?
≥2 semen analyses with ≥1 variables <5th centile
72
What are the contraindications to intrauterine insemination (IUI)
1) Couples with unexplained infertility
2) Women with mild endometriosis
3) Men with mild male factor infertility (≥2 semen analyses with ≥1 variable <5th centile)
Only offer to them if they have cultural, social or religious objections to IVF
Advise these couples to try to conceive for a total of 2 years (including up to 1 year before their fertility investigations) before IVF will be considered
73
What factors are used to predict IVF success?
1) Female age
The chance of a live birth following IVF decreases with increasing age
2) Previous IVF cycles
The chance of a live birth following IVF decreases as the number of unsuccessful cycles increases
3) Previous pregnancy history
IVF is more effective in women who have previously been pregnant and/or had a live birth
4) BMI
Female BMI should be between 19-30 before commencing assisted reproduction, outside of this decreases the chance
5) Lifestyle factors
>1 unit/day alcohol decreases the effectiveness of assisted reproduction. Maternal and paternal smoking decreases success rate. Maternal caffeine decreases success rates
74
What does a full cycle of IVF entail?
One episode of ovarian stimulation and transfer of any fresh or frozen embryos
75
A 38 year old woman attends her GP after trying to conceive for >1 year. What should she be offered?
Investigations into her fertility:
- TVS pelvis
- Semen analysis for partner
- Viral infection screen - HIV, Hep B, Hep C, Rubella
- Ovarian reserve testing - AMH, FSH or Antral follicle count
- Screen for Chlamydia if you have to instrument the uterus, i.e. HSG or HysCoSy
- Confirmation of ovulation:
Mid-cycle progesterone (D21 progesterone)
FSH + LH (D2-3) with D21 progesterone if prolonged irregular cycles
-Earlier referral for IVF (as >36)
76
A 38 year old woman attends her GP after trying to conceive for >2 years. A year ago she was investigated for infertility and no cause was found (unexplained infertility). What is her further management?
Refer for IVF
77
A 38 year old woman attends her GP after trying to conceive for >2 years. A year ago she was investigated for infertility and no cause was found (unexplained infertility). How many cycles of IVF is she entitled to?
3
Women <40 who have not conceived after 2 years of regular sexual intercourse or 12 cycles of artificial insemination (where ≥6 were IUI) offer 3 full cycles of IVF with/without ICSI
If she turns 40 during a treatment cycle then complete that cycle but do not offer anymore
78
A 40 year old woman attends her GP after trying to conceive for >2 years. A year ago she was investigated for infertility and no cause was found (unexplained infertility). How many cycles of IVF is she entitled to?
1
Women 40-42 years old who have not conceived after 2 years of regular intercourse or 12 full cycles of artificial insemination (where ≥6 were IUI) offer 1 full cycle of IVF with/without ICSI, IF the following criteria are met:
1) Never had IVF before
2) No evidence of low ovarian reserve
3) There has been a discussion regarding the implications of IVF and pregnancy at this age
79
A 43 year old woman attends her GP after trying to conceive for >2 years. A year ago she was investigated for infertility and no cause was found (unexplained infertility). How many cycles of IVF is she entitled to?
0
80
If investigations into infertility show that there is no chance of pregnancy with expectant management what is the management?
Refer for IVF
81
A 39 year old woman attends for IVF. She previously had 2 cycles of IVF done privately, which resulted in two early miscarriages. How many cycles of IVF is she offered?
1
In women <40 any previous full IVF cycle, either private or NHS should count towards the total of 3 full cycles that should be offered by the NHS
82
What does it mean by a 'cancelled IVF cycle'?
A cancelled IVF cycle is where an egg collection isn't performed
Cancelled IVF cycles due to low ovarian reserve should be taken into account when considering suitability for further IVF
83
Which women can you offer GnRH agonists for ovarian stimulation in IVF cycles?
Women with a low risk of OHSS
When using GnRH agonists as part of IVF treatment use a long down-regulation protocol
84
When using gonadotrophins for ovarian stimulation in IVF:
1) Use an individual starting dose of FSH based on factors that predict success, i.e.
- Age
- BMI
- Presence of polycystic ovaries
- Ovarian reserve
2) Don't use FSH >450 IU/day
85
What is the process of IVF?
1) Clomifene citrate (SERM) or Gonadotrophins (FSH+LH) for ovarian stimulation
2) US monitoring throughout ovarian stimulation (with or without oestradiol levels) for safety and efficacy
3) hCG trigger
4) Egg retrieval
5) IVF
6) Embryo transfer
86
Which medication is given to trigger ovulation in IVF treatment?
hCG (urinary or recombinant)
offer US monitoring of ovarian response as an integral part of IVF
87
What thickness of the endometrium is needed for US-guided embryo transfer?
≥5mm
Offer US-guided embryo transfer as it increases pregnancy rates
Replacement of embryos into an endometrium <5mm is unlikely to result in pregnancy and is not recommended
88
A 35 year old woman is undergoing IVF for unexplained infertility. She has had an egg retrieval and successful IVF. How many embryos can be transferred in one cycle?
Women <37 years:
1) In the first cycle transfer ONE embryo (single embryo transfer)
2) In the 2nd cycle transfer ONE embryo if ≥1 top quality embryo. Or transfer up to 2 embryos if no top quality embryos available
3) In the 3rd cycle transfer no more than 2 embryos
89
A 38 year old woman is undergoing IVF for unexplained infertility. She has had an egg retrieval and successful IVF. How many embryos can be transferred in one cycle?
Women >37 years and <40 years:
1) In the first and second cycle transfer one embryo if ≥1 top quality embryos available. Transfer up to 2 embryos if no top quality embryos available (double embryo transfer)
2) In the 3rd cycle transfer no more than 2 embryos
90
A 41 year old woman is undergoing IVF for unexplained infertility. She has had an egg retrieval and successful IVF. How many embryos can be transferred in one cycle?
Women ages 40-42:
- Double embryo transfer
91
How is luteal phase support is given in IVF?
Cyclogest 400 micrograms BD pv for up to 12/40
Don't give hCG for luteal phase support as it increases the risk of OHSS
There is no evidence to support continuing luteal phase support >8/40
92
What are the indications for ICSI (Intracytoplasmic Sperm Injection)?
1) Men with severe semen defects
2) Obstructive azoospermia
3) Non-obstructive azoospermia
4) Previous failed IVF cycle or very poor fertilisation
ICSI increases fertilisation rates compared to IVF alone
But when fertilisation is achieved the pregnancy rate is no better than with IVF
93
If the indication for ICSI is severe deficit in semen quality or non-obstructive azoospermia, what further testing should the man have?
Karytopying
The man should have genetic counselling regarding the genetic abnormalities which may be detected
Testing for Y chromosome microdeletions is not routine before ICSI - but a significant proportion of male infertility is caused by this which is involved in the regulation of spermatogenesis
94
In women undergoing donor insemination when should investigations for tubal damage be performed?
Before donor insemination if the history is suggestive of tubal damage
In women with no risk factors for tubal damage after 3 failed cycles of donor insemination
If using donor insemination use IUI instead of intracervical insemination as it has higher pregnancy rates
95
What are the indications for oocyte donation?
1) Primary ovarian insufficiency/Premature ovarian failure
2) Ovarian failure secondary to Chemo or Radiotherapy
3) Bilateral Oophorectomy
4) Gonadal dysgenesis, i.e. Turner's syndrome
5) Certain cases of IVF failure
6) High risk of transmitting a genetic disorder to the offspring
96
When can you offer embryo cryopreservation for women of reproductive age (including adolescent girls) who are preparing for chemo or radiotherapy?
1) They are well enough to undergo ovarian stimulation and egg retrieval
AND
2) This will not worsen their condition
AND
3) There is enough time to undergo this before starting their cancer treatment
Offer to transgender men
97
What is the incidence of infertility in the UK?
Infertility affects 1 in 7 heterosexual couples in the UK
98
What are the main causes of infertility?
1) Male infertility - 30%
2) Unexplained infertility - 25% (no male or female cause found)
3) Ovulation disorders - 25%
4) Tubal factors - 20%
5) Uterine or peritoneal disorders - 10%
99
In what % of cases are disorders of fertility found in both the man and the woman?
40%
100
What investigations into infertility are provided?
1) Semen analysis
2) Assessment of ovulation
3) Assessment of ovarian reserve
4) Screening for infections - HIV, Hep B, Hep C, Rubella
5) TVS pelvis
6) TFTs
101
In unexplained infertility what are the chances of spontaneous conception within the first 12 months?
75%
In unexplained subfertility chances of conceiving with expectant management are high with 74% of couples conceiving within 12 months
102
What is the most common cause of hyperandrogenism in women of reproductive age?
PCOS
103
What is the most common cause of ambiguous genitalia?
Congenital adrenal hyperplasia
104
What percentage of subfertile men with azoospermia or oligospermia have Klinefelter's syndrome?
10-15%
105
What is the incidence of mayer rokitansky kuster hauser syndrome?
1 in 5,000
106
What proportion of patients with mayer rokitansky kuster hauser syndrome have an associated renal abnormality?
40%
107
Premature ovarian failure is defined as the cessation of ovarian function below what age? In what proportion of women does it affect?
<40 years old
1% of women
108
Male infertility makes up what proportion of infertility?
30%
109
Ovulation disorders make up what proportion of infertility?
25%
110
Unexplained infertility makes up what proportion of infertility?
25%
111
Tubal damage makes up what proportion of infertility?
20%
112
Uterine or peritoneal disorders make up what proportion of infertility?
10%
113
Combined male and female factors make up what proportion of infertility?
40%
114
What is the failure rate with laparoscopic sterilisation with filschie clips?
2-5 in 1,000
115
What is the failure rate with hysteroscopic sterilisation?
2 in 1,000
116
What proportion of successful IVF procedures results in multiple pregnancies?
Up to 24%
117
What is the incidence of premature ovarian failure in women under 40?
1%
Premature ovarian failure affects 1% of women under 40
118
What proportion of premature ovarian failure is idopathic?
90%
119
Women with a BMI>30 have a decreased likelihood of live pregnancy compared to women with a BMI <30, by how much?
70%
120
A 35-year-old woman with subfertility is undergoing abdominal myomectomy. What are the chances of her achieving a spontaneous pregnancy assuming that there are no associated factors that may affect her fertility?
67% (2/3)
121
What is the prevalence of ectopic pregnancy following natural conception?
1-2%
