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Y4 CBLs > Obs&Gyn: Infertility > Flashcards

Obs&Gyn: Infertility Flashcards

1
Q

Simple description of menstrual cycle

A
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2
Q

Spermatogenesis

A
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3
Q

Define infertility

A

Failure to conceive after regular unprotected sexual intercourse for 1 year in the absence of known reproductive pathology

Subfertility - conceiving is possible but takes longer (is delayed)

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4
Q

Advice on frequency and timing of sexual intercourse

A
  • intercourse every 2 to 3 days optimises the chance of pregnancy
  • Timing intercourse to coincide with ovulation (ovulation testing kits) causes stress and is not recommended
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5
Q

Lifestyle advice for a couple trying to conceive/ struggling with infertility

A
  • Drinking no more than 1 or 2 units of alcohol once or twice a week and avoiding episodes of intoxication – “binge drinking”
  • Excessive alcohol consumption is detrimental to semen quality
  • Smoking is likely to reduce fertility in women and men (impotence, and congenital abnormalities)
  • BMI > 29 or more is associated with reduced fertility in men and women
  • Rubella screening and regular folic acid
  • Dietary advice
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6
Q

Infertility factors statistics (%) by gender

A

Female factor – 40%

Male factor – 30%

Combined – 30%

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7
Q

Female causes of infertility

A
  • Uterus and tubes
  • Cervical mucus
  • Fallopian tube damage
  • Uterine fibroids/septum
  • Ovulation Disorders
  • Medicines, drugs and medical disorders
  • Age
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8
Q

Male causes of infertility

A
  • Sperm disorders
  • Testicular disorders
  • Ejaculation problems
  • Medicines and drugs
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9
Q

General History taking points

A
  • Both partners should be present
  • Age
  • Previous pregnancies by each partner
  • Length of time without pregnancy within current relationship
  • Sexual history
  • Frequency and timing
  • Use of lubricants
  • Impotence, dyspareunia
  • Contraceptive history
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10
Q

What to ask about in the history from male?

A
  • Occupation – use of toxins/pesticides/cadmium/mercury/long distance lorry driver
  • Alcohol, smoking
  • Showers vs baths – excessive heat exposure
  • Sexual development and structural anomalies
  • Surgery – hernias/varicocele/prostate
  • Orchitis (mumps)
  • Systemic illness or viral illness
  • Erectile dysfunction (IDDM, MS, paraplegia/drugs)
  • Drugs – anti-androgens, chemotherapy, anabolic steroids
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11
Q

What to ask about in history from female

A
  • Menstrual history e.g. LMP, cycle, onset
  • Gynae history – smears, contraception, previous pregnancies, PID/STI, appendicitis, IUD use, ectopic pregnancy history/tubal surgery, endometriosis, cervical and uterine surgery, sterilisation
  • PMH – chronic conditions eg. Diabetes, thyroid disorders
  • SH – alcohol, smoking, illicit drugs
  • FH – PCOS, congenital abnormality
  • Stress
  • Exercise
  • Weight changes
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12
Q

What couples not to investigate for infertility problems?

A
  • Patient not sexually active
  • Patient not in long term relationship
  • Patient declines treatment at this time
  • Couple does meet the definition of an infertile couple
  • Very young
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13
Q

What to look at during physical examination in male?

A
  • Size of testes
  • Testicular descent
  • Varicocele
  • Outflow abnormalities (hypospadias)
  • Thickened epididymis
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14
Q

What to look at during examination in female?

A
  • Pelvic masses
  • Abdomino-pelvic tenderness
  • Uterine enlargement
  • Thyroid examination
  • Uterine mobility
  • Cervical abnormalities
  • Utero-sacral nodularity
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15
Q

Bloods in Ix for infertility

A
  • Confirmation of ovulation – “day 21” progesterone
  • Follicular phase bloods – day 2-4
  • FSH, LH, oestradiol, prolactin, testosterone, DHEAS, androstenedione, SHBG, FAI
  • Rubella and chlamydia serology
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16
Q

Ix for tubal potency

A

Evaluate tubal patency whenever there is a history of PID, endometriosis or other adhesiogenic condition

Tests:

  • Hysterosalpingogram
  • Hycosy (hystero-salpingo contrast sonography)
  • Laparoscopy and dye test
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17
Q

Describe Hysterosalpingogram (HSG)

A
  • Radiologic procedure requiring contrast
  • Performed optimally in early proliferative phase (avoids pregnancy)
  • Oil-based contrast (higher risk of anaphylaxis)
  • Can be uncomfortable
  • Pregnancy test advisable
  • Can detect intrauteine and tubal disorders but not always definitive
18
Q

Describe HyCoSy

A

Hystrosalpingo Contrast Sonography

  • Transvaginal ultrasound technique
  • Contrast solution of galactose (Echovist) is infused into the uterine cavity and observed to flow along the fallopian tubes to assess patency
  • HyCoSy needs to be carried out between day 8 and 12 of a natural unprotected menstrual cycle or anytime in the cycle if reliable contraception is used
19
Q

Male investigations

A
  • Semen Analysis
  • If semen analysis normal consider
  • FSH/LH
  • Testosterone
20
Q

Criteria for semen analysis

A
  • Semen analysis after abstinence from sex for 4 days
  • Repeat test should be offered only after 3 months
  • In presence of gross abnormality – sooner, or as soon as possible
  • To the lab ASAP (< 60 mins) kept at body temperature
21
Q

Interpretation of serum progestogen

A
22
Q

Management of infertility

A
  • If investigations normal and couple trying for short time – reassure
  • If relatively young “wait and see” policy for 2 years
  • Anovulation → clomiphene (an ovulatory stimulant) or tamoxifen
  • Metformin if PCOS
  • Ovarian drilling
  • Tubal problem – IVF
  • Male factor – testicular biopsy, ICSI (intracytoplasmic sperm injection), donor insemination
23
Q

Assisted reproductive techniques list

A
  • IUI (intrauterine insemination
  • IVF (In vitro fertilisation)
  • ICSI (intracytoplasmic sperm injection)
  • Donor insemination
  • Egg donation
  • Egg freezing
  • PGD (preimplantation genetic diagnosis) used in couples with history of genetic disorder
24
Q

IVF vs IUI

A
25
Q

IVF vs ICSI

A
26
Q
A
27
Q

Types of dysmenorrhoea

A
  • primary → coming with period (e.g. lower abdominal cramps)
  • secondary → coming few days before bleed and finishing few days after (maybe pathological e.g. adenomyosis, endometriosis)
28
Q

Types of dyspareunia

A
  • superficial → as the penis enters e.g. vaginismus (psychological)
  • deep → pathological e.g. cervical cancer, ectropion
29
Q

Why do we do bloods in 2-3 day of a menstrual cycle?

A

They are then at a baseline level

(to check for hormonal baseline)

30
Q

Types of infertility (2)

A
  • Primary → a person never has had kids
  • Secondary→ a person has had a child but can’t get pregnant again
31
Q

Why Day 2 FSH may be higher in older ladies?

A

It is higher as more FSH needed to stimulate poorly responsive follicular maturation

32
Q

Class and MoA of Clomiphene

A

Clomiphene is anti-oestrogen

it works via negative feedback → less oestrogen = more FSH will be produced → ovulation

33
Q

Difference between ICSI and IVF

A
  • ICSI → sperm taken and injected into the egg cell
  • IVF → sperm and egg in one dish; sperm needs to penetrate egg itself
34
Q

Characteristics of ovarian cyst in PCOS

A
  • dense stroma
  • ‘pearl necklace’ appearance (immature follicles)
  • hydrodese shell/capsule
35
Q

What about testosterone and SHBG levels in PCOS?

A
  • SHBG levels low → as more testosterone is bound to it (so less saturated)
  • Testosterone level is high
36
Q

What’s a typical LH:FSH ratio in PCOS?

A

LH: FSH ratio in PCOS is typically 3:1

37
Q

Do we give any fertility treatments to a woman with BMI >30?

A

No! If a woman would get pregnant her BMI increases even further → so more harm than good

We first need to get woman’s BMI to 30 or less

38
Q

Outline steps in management of infertility in PCOS

A
  • lifestyle (to get BMI to 30)
  • Clomiphene/ Tamoxifen
  • Metformin
  • referral (if the above don’t work)
39
Q

(2) differentials for a woman with high testosterone

A
  • Congenital Adrenal Hyperplasia
  • PCOS
40
Q

After what period of time do we repeat sperm analysis?

A

only after 3 months as sperm need to replenish itself

Y4 CBLs (32 decks)

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