Reproductive medicine

Question 1

What is needed to achieve a pregnancy?

Answer 1

Functioning menstrual cycle:
ovulation
endometrial thickening

Healthy fallopian tubes

Healthy sperm

Question 2

What preconceptional advice is given to women?

Answer 2

Stop smoking
No alcohol intake
BMI < 19 and > 30 impact fertility

Impact of caffeine is still unclear
Complementary therapy - unclear benefit

Consider any occupational hazards
Stop recreational drug use

Question 3

What preconceptional advice is given to men?

Answer 3

Stop smoking
Alcohol 3 – 4 units / week
BMI > 30 likely to reduce fertility

Elevated scrotal temperature is associated with reduced semen quality, but uncertain whether wearing loose-fitting underwear improves fertility

Question 4

How often should sexual intercourse occur to optimise natural fertility?

Answer 4

Every 2-3 days

Question 5

What preconceptional vitamin supplements are given to women?

Answer 5

Folic acid
(0.4mg/day OR 5mg/day)

Vitamin D
(10mcg/day)

Question 6

When might 5mg/day of folic acid be given to women instead of 0.4mg?

Answer 6

Previous child with neural tube defect

Personal or family history of neural tube defect for either partner

Diabetes mellitus (type 1 and type 2)

Coeliac disease

BMI ≥ 30 kg/m2

Inherited haemoglobinopathies including carrier states (thalassemia trait)

Anti-folate medication – (sulpha drugs)

Question 7

What are the four main categories of causes of infertility?

Answer 7

Disorders of ovulation
Male factors
Pelvic pathology
Unexplained

Question 8

What are the three different WHO classifications of anovulatory infertility?

Answer 8

Group 1: hypothalamic pituitary failure

Group 2: hypothalamic-pituitary-ovarian dysfunction

Group 3: ovarian failure

(other causes: hyperprolacintaemia)

Question 9

What is group 1 anovulatory infertility?

Answer 9

hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism).

(commonly athletes, dancers etc - BMI >19)

Question 10

What is group 2 anovulatory infertility?

Answer 10

hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome).

Question 11

What is group 3 anovulatory infertility?

Answer 11

Ovarian failure

Question 12

What are oestrogen and FSH levels like in group 1 anovulatory infertility?

Answer 12

Oestrogen low

FSH low or normal

Question 13

What are oestrogen and FSH levels like in group 2 anovulatory infertility?

Answer 13

Oestrogen normal

FSH normal

Question 14

What are oestrogen and FSH levels like in group 3 anovulatory infertility?

Answer 14

Oestrogen low

FSH high

Question 15

How would you manage someone who has a group 1 ovulation disorder?

Answer 15

If BMI < 19 - increase weight

if high levels of exercise - moderate exercise

treatment - gonadotrophin for ovulation induction

Question 16

What is the female athlete triad that impacts fertility?

Answer 16

Low energy availability/eating disorders

Low bone mass

menstrual disturbance

Question 17

What is the most common cause of group 2 anovulatory infertility?

Answer 17

PCOS

Question 18

What is the triad of PCOS symptoms called? What are they?

Answer 18

Rotterdam criteria - need 2 of:

Polycystic ovaries on US
Oligo/anovulation
Clinical/biochemical hyperandrogenism

Question 19

How would you manage anovulation in PCOS?

Answer 19

Consensus algorithm

FIRST LINE
If no ovulation: lifestyle +/- bariatric surgery

SECOND LINE
If no ovulation: Clomiphene citrate (CC) or letrozole

THIRD LINE
Gonadotrophins OR
CC + metformin OR
Laparoscopic ovarian diathermy

FOURTH LINE
IVF

If at any stage the woman starts ovulating, leave for 6-9 cycles to conceive naturally. If this doesn’t occur - IVF

Question 20

What are the diagnostic criteria for group 3 ovulation disorders (Premature ovarian insufficiency)?

Answer 20

Oligo/amenorrhoea for at least 4 months

Elevated FSH level >25
on 2 occasions
> 4 weeks apart.

Patient <40yrs

Question 21

What are some causes of premature ovarian insufficiency?

Answer 21

Turner syndrome
Chromosomal material
Fragile X
Anti-adrenal antibodies
Thyroid peroxidase antibodies

Question 22

How would you manage group 3 (premature ovarian insufficiency) ovulation disorders?

Answer 22

Fertility treatment

Oocyte donation

HRT (prevent osteoporosis)

(no interventions to increase ovarian activity and natural conception rates)

Question 23

What are some causes of pelvic pathology that could inhibit reproduction?

Answer 23

PID
Endometriosis
Past abdo/pelvic infection or surgery

Question 24

How could you investigate pelvic causes for reduced fertility?

Answer 24

hysterosalpingography (low risk women)

hysterosalpingo-contrast-ultrasonogrpahy

GOLD STANDARD: LAPAROSCOPY

Question 25

What should a male sperm count be? What is it called if this is not the case?

Answer 25

>=15 million/ml Oligozoospermia

Question 26

What should the progressive motility of male sperm be? What is it called if this is not the case?

Answer 26

>=32% Asthenozoospermia

Question 27

what is the lower limit of percentage of sperm with normal morphology, that is required for sufficient male fertility? What is it called if this is not achieved?

Answer 27

4% Teratozoospermia

Question 28

What are some causes of male infertility?

Answer 28

Idiopathic (most common) Hypogonadism (medically treatable) Genetic causes Testicular trauma/surgery/developmental abnormalities Obstructive (vasectomy/infection) Anabolic steroids (not always reversible) Previous chemotherapy

Question 29

How is male infertility managed?

Answer 29

If there is sperm in the ejaculate: ICSI If there isn't sperm in the ejaculate: surgical sperm retrieval or donor sperm

Question 30

How should unexplained infertility be managed?

Answer 30

Exclude all causes Recommend 2 years of trying IVF (ovulation induction and intrauterine insemination are not of benefit)

Question 31

When can IUI be used?

Answer 31

difficulty with sexual intervourse: physical disability psychosexual issues donor sperm

Question 32

What is the process of IVF?

Answer 32

Egg production stimulated by hormone therapy (injections) Eggs retrieved from woman's body in minor surgical procedure under sedation Sperm sample provided Eggs and sperm combined in lab to allow fertilisation (if ICSI, pick best sperm and eject them on the same day) Embryo left to grow for 2-6 days Embryo with best chance of survival chosen Fertilised embryo introduced into womb (procedure feels like a smear) Medicines taken to give embryo best chance of survival 2 weeks later: PT Ultrasound 3 weeks later

Question 33

What is ovarian hyper stimulation syndrome (OHSS)?

Answer 33

Too much hormone given = some serious symptoms for women. Can be life-threatening.

Question 34

What are some symptoms of mild OHSS?

Answer 34

Abdo bloating Mild abdo pain Ovarian size <8cm

Question 35

What are some symptoms of moderate OHSS?

Answer 35

Abdo pain nausea and vomiting USS of ascites Ovarian size 8-12

Question 36

What are some symptoms of severe OHSS?

Answer 36

``` Clinical ascites oliguria hyponatraemia hyperkalaemia hypo-osmolality hypoprotinaemia ovarian size >12 cm ```

Question 37

What are some symptoms of critical OHSS?

Answer 37

Tense ascites Haematocrit >0.55 WCC >25000 Oliguria/anuria

Question 38

If a woman in undergoing IVF and complains of abdo pain, nausea and vomiting and has signs of fluid retention, what would you suspect? How would you investigate and confirm diagnosis?

Answer 38

Ovarian hyperstimulation Ultrasound pelvis and abdomen Bloods

Question 39

What advice can be given to men about fertility preservation? When should these be done

Answer 39

Post-pubertal boys and adults: sperm cryopreservation Pre-Pubertal boys: currently no clinically advisable option Advisable to discuss these options prior to therapy that potentially affects fertility: chemo radio surgery: testicular, reproductive tract, retroperitoneal nerve plexus

Question 40

What advice can be given to women about fertility preservation? When should these be done

Answer 40

GnRH analogies for ovarian suppression - been shown to have some success in women receiving chemo for breast cancer oocyte/embryo cryopreservation social egg freezing/anticipation of age-related decline in fertility

Question 41

What are the risks of egg donation? How does age impact egg donation?

Answer 41

Hypertensive disorders of pregnancy Pre-term birth Low birth weight Pregnancy > 40: increased maternal and foetal risks