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Monica’s Part 2 > Subfertility > Flashcards

Subfertility Flashcards

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1
Q

What is the absolute risk of aortic dissection in pregnancy in women with Turner S?

A

1%

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2
Q

When is pregnancy contraindicated in Turner syndrome?

A

If aorta has an absolute diameter of >35mm

or

25mm/m2 and there is a history of aortic surgery or there is uncontrolled hypertension despite treatment

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3
Q

Any considered risk factors with pregnancy in TS?

A

The presence of a bicuspid valve or coarctation

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4
Q

What is the risk of miscarriage after natural conception for women with TS

A

31-45%

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5
Q

Maternal complications for TS in pregnancy with donor oocytes or embryos

A

-miscarriage rates appear to be similar to the general population 25%

-increased risk of hypertension - 15-17%

-aortic dissection 1-2%

  • CS rates 80-100%
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6
Q

Fetal complications for TS in pregnancy with donor oocytes or embryos

A

-preterm birth incidence is higher - 12-38%

-SGA (weighing less than 2500g 18-57%

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7
Q

Chances of conception in couples with in one year

A

80%

  • need to be less than 40 and have regular intercourse
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8
Q

Chances of couple conceiving in 2 years

A

Of those who do not conceive in the first year - half will conceive in the Second year- cumulative preg rate over 90%

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9
Q

Inform people who have IUI that…

A

their fertility that:
o over 50% of women aged under 40 years will conceive within 6 cycles of intrauterine
insemination (IUI) of those who do not conceive within 6 cycles of intrauterine
insemination, about half will do so with a further 6 cycles (cumulative pregnancy rate
over 75%).
Inform people who

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10
Q

Sperm - frozen or fresh

A

Fresh

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11
Q

AFC
Low
Mod
High

A

Low - less than 4
Mod 4-16
High more than 16

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12
Q

FSH

A

Low - more than 8.9
Mod- 4- 8.9
High - less than 4

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13
Q

AMH
Low
Mod
High

A

Low <5.4
Mod 5-25
High >25

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14
Q

If irregular cycles how to check for ovulation?

A

repeat progesterone weekly after initial possible mid lateral phase

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15
Q

What can be surgically managed ? And what not?

A

Obstructive azoospermia should be offered surgical correction of epididymal blockage - surgical correction should be considered as an alternative to surgical stem recovery and IVF

No surgical treatment for varicoceles as a form of of fertility treatment

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16
Q

Clomid - how long to take

A

No longer than 6 months

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17
Q

If on clomid what do you do

A

Offer USS at least in the first cycle of treatment to ensure they are taking a dose that minimizes the risk of multiple pregnancy

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18
Q

GNRH agonists

A

Only offer gonadotrophin-releasing hormone agonists to women who have a low risk of ovarian hyperstimulation syndrome.
When using gonadotrophin-releasing hormone agonists as part of IVF treatment, use a long down-regulation protocol.

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19
Q

Embryo transfer strategies in IVF into uterine cavities

A

Replacement of embryos into a uterine cavity with an endometrium of less than 5 mm thickness is unlikely to result in a pregnancy and is therefore not recommended.

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20
Q

Transferring fresh or frozen embryos
Under 37

A

In the 1st IVF - use a single embryo

In the 2nd cycle use a single embryo if 1 or more top quality embryos are available
-consider 2 embryos if no top quality there

In the 3rd cycle - no more than 2 embryos

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21
Q

Transferring fresh or frozen embryos
Age 37-39

A

In the 1st and 2nd ful IVF cycle use single embryo transfer if there are 1 or more top-quality embryos
-consider 2 if no top quality

In the 3rd cycle - transfer no more than 2 embryos

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22
Q

Transferring fresh or frozen embryos
Age 40-42

A

Consider double embryo transfer
- no more than 2 embryos should be transferred during one cycle
- where a top-quality blastocyst is available use a single embryo transfer

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23
Q

Treatment for luteal phase of pregnancy is

A

Progesterone for 8 weeks no longer , not HCG
-if you give HCG in IVF it can increase chance of ovarian stimulation

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24
Q

Indications for ICSI (4)

A

Quality obstructive
Severe deficits in semen
Non-obstructive azoopspermia
Azoospermia

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25
Karyotyping with ICSI?
Where the indication for ICSI is a severe deficit of semen quality or non- obstructive azoospermia, the man's karyotype should be established.
26
Post donor insemination if failed what to do?
If failed 3 times or 3 cycles - offer tubal assessment
27
Oocyte donation when
Gonadal dysgenesis (turners Bilateral oophorectomy ovarian failure following chemo or radio Certain cases of IVF treatment failure Can be considered in high risk if genetic condition passing of
28
Male subfertilty rates
Sixteen percent of couples will fail to conceive after 1 year of trying.1 A male factor alone is thought to contribute in up to 30% of these cases,
29
Causes of male infertility Preterticular
● Hypothalamic disease ‐ Gonadotrophin deficiency (Kallman syndrome) ● Pituitary disease ‐ Pituitary insufficiency (tumours, radiation, surgery) ‐ Hyperprolactinaemia ‐ Exogenous hormones (anabolic steroids, glucocorticoid excess, hyper- or hypothyroidism) ↓Fsh ↓lh Hypogonadotrophic hypogonadism
30
Causes of male infertility Testilular
Testicular: ● Congenital Genetic ‐ Chromosomal (Kleinfelter syndrome 47, XXY) ‐ Y chromosome microdeletions ‐ Noonan syndrome (male Turner syndrome 45, XO) Other ‐ Cryptorchidism ● Acquired ‐ Injury (orchitis, torsion, trauma) ‐ Varicocele ‐ Systemic disease (renal failure, liver failure) ‐ Chemotherapy, radiotherapy ‐ Testicular tumours ‐ Idiopathic Hypergonadotriphic hypogonadism or High FSH, normal testosterone and LF
31
Post testicular male subfertility
Post-testicular (obstruction): ● Congenital ‐ Cystic fibrosis, congenital absence of the vas deferens (CAVD) ‐ Young’s syndrome ● Acquired ‐ Vasectomy ‐ Infection (chlamydia, gonorrhoea) ‐ Iatrogenic vasal injury ● Disorders of sperm function or motility ‐ Immotile cilia syndrome ‐ Maturation defects ‐ Immunological infertility ‐ Globozoospermia ● Sexual dysfunction ‐ Timing and frequency ‐ Erectile/ ejaculatory dysfunction ‐ Diabetes mellitus, multiple sclerosis, spinal cord/pelvic injuries
32
Male factor subfertility Post- testicular
Post-testicular (obstruction): ● Congenital ‐ Cystic fibrosis, congenital absence of the vas deferens (CAVD) ‐ Young’s syndrome ● Acquired ‐ Vasectomy ‐ Infection (chlamydia, gonorrhoea) ‐ Iatrogenic vasal injury ● Disorders of sperm function or motility ‐ Immotile cilia syndrome ‐ Maturation defects ‐ Immunological infertility ‐ Globozoospermia ● Sexual dysfunction ‐ Timing and frequency ‐ Erectile/ ejaculatory dysfunction ‐ Diabetes mellitus, multiple sclerosis, spinal cord/pelvic injuries
33
What is the mean byline of a testicle in an adults
A mean volume of 20 ml in the adult is considered normal Consistency can be described as firm (normal), soft or hard (abnormal).
34
Most common sex chromosomal abnormality in men
Kleinefelter syndrome 47 XXY
35
Microdeletions on Y chromosome
As many as 10–15% of men with azoospermia and 5–10% of men with severe oligospermia have underlying micro-deletions in one or more gene regions implicated in spermatogenesis, on the long arm of the Y chromosome (Yq). This region includes the Azoospermia Factor (AZF) locus, which contains three subregions: AZFa, AZFb, and AZFc. AZFc micro-deletions have a good prognosis for surgical sperm recovery whereas the prognostic value for sperm recovery in AZFa and AZFb micro-deletions is poor51 and such individuals should not be offered surgical sperm retrieval.
36
Imaging with absent vas def?
If an absent vas is detected on examination, a renal ultrasound scan is recommended, as up to 30% of such men may have a renal abnormality.
37
Testicular biopsy specimens can be classified histologically
normal (appropriate number of cells with complete spermatogenesis)  hypospermatogenesis (all cell types present and in correct ratio but at reduced cell number  maturation arrest (failure of spermatogenesis beyond a certain stage; can be ‘early’ or ‘late’)  sertoli cell-only (del Castillo) syndrome (no germ cells).
38
Treatment for pre testicular
GNRH or exogenous gonadotrophins
39
Types of azoospermia
40
Alzoospermia how much is obstructive
40%
41
UK fertility clinics must comply with
1. Human fertilization and embryology HLE act 1990 2. The HFE 2008
42
Definition of POI
FSH > 25IU/L on 2 samples 4 weeks apart
43
Genetic causes of POI
Turner’s syndrome Fragile x Autosomal disorders including galactosaemia
44
Outcomes of live births of fresh vs frozen donor oocytes
56.4% fresh vs 45.3% frozen
45
Main risk factors for complications using donated oocytes is
Severe pre-eclampsia
46
Do endometiromas recur
Yes 30% in 2-5 years post op 81% occur int he treated ovary
47
How common are endometriomas
17-44% One third of them have bilateral cysts
48
What is the gold standard for endo diagnosis
MRI and advanced USS are considered as first line
49
Deep endo with endometrioma?
50% of women with deep endo will have an associated endometrioma
50
POI after bilateral systectomie for endometrioma is
2.4%
51
Risk of infection pelvic infection with and endometrioma undergoing egg collection is
<1% Antibiotics are recommended as good practice for women with endometriosis undergoing ART are they are considered to be a high risk of pelvic infection
52
What improves AMH medication wise
Dienogest
53
Is there uterine remodeling with endo in preggo ppl
Only partial vascular remodeling in endo Absent remodelling in PET Increases preterm birth , premature rupture of membranes and FGR
54
Effect of altered juntional zone and vasculature bed remodelling in endo with preg
Placenta Praevia (deffective implantation )
55
Defective placentation effect on pregnancy
SGA FGR PET Preterm birth
56
Rate of sponsors hemorrhage in preg
19-55%
57
Unprovoked intrapersonal lede in in pregnancy incidence rate
1 in 10 000
58
Fetal mortality in the 3rd trimester with sponatous haemorrgae in pregnancy
31%
59
Endo and risk of uterine rupture?
In nulliparous women both before and during labor or uterine scar weakness, following excision of rectovaginal nodule or electrosurgical treatment of stage 4 endo
60
Pathophysiology of SHip - spontaneous haemoperitonium in pregnancy
Common - -Involution of decidualised (progesterone mediated) endometriosis implants - associated with parametrial veins causing vascular fragility and spontaneous peritoneal bleeding (very rare) -chronic inflammation - causes tissues affected by endo to be more friable
61
For high risk endo group: Preconception counseling
Increased risk of miscarriage rate, PIH, PET, GA STD, PP, CS PPH neonatal admission Increased risk of perineal injuries - 3rd, 4th, deg tears at vag del in cases o recto vag endo
62
For high risk endo group Antenatal care
At cons led unit BP monitoring Consider aspirin Endometrioma surveillance on USS Serial growth scans for SGA and rout out PP
63
For high risk endo group Intrapartum
Continuous CTG Increased risk of failed induction of labour and obstructed labour Early recourse to caesarean section in case of unexplained , abdo pain, hypotension, haematuria, since risk of SHIP , urethral rupture and uterine rupture even in nuliparous snowmen in unscarred uterus Senior obstetrician to be present at CS in prev surgically treated endo.
64
Preferred imaging modality in pregnancy with endo
MRI with doalinium is adnantegous , USS is limited by the large uterus
65
Women with endo are at risk of what when menopause and endo
Women with endo have an increased risk of cardiovascular disease irrespective of whether they had an early surgical menopause
66
Increased risk of miscarriage with endo?
Yes, potential increased risk of miscarriage and ectopic pregnancy in 1st timester
67
For deep endometriosis involving the bowel, bladder or ureter, consider:
pelvic MRI before operative laparoscopy • a 3-month course of GnRHa before surgery. Consider hormonal treatment after laparoscopic excision or ablation.
68
If hysterectomy is indicated: For endo (in nice guidelines)
excise all visible endometriotic lesions at the time of hysterectomy • discuss with the person what a hysterectomy is, its risks & benefits, related treatments and likely outcome.
69
Average pregnancy rates after ICSI
33%
70
How can sperm be retrieved
Either from the testes or from the epididymis for IVF or ICSI-indications + obstructive causes severe male factor infertiltly - ejaculatory failiure Super from the epididymis can be retrieved bia MESA- micro surgical or PESA epididymal sperm aspiration under local anaesthetic
71
Can you treat low FSH and low LH in men (hypogonadiptriphic hypogonadism ?
Yes with GNRH or exogenous gonadotrophins
72
Indications for IUI
Mild male factor infertility - up to 6 cycles Immunologic infertility Mechanical problems NICE- mild oligozoospernia one or more variables below the 5th centile (as defined by the WHO, 2010).
73
Test for female hypogonadotrophic hypogonadism
Day 2-5 FSH and LH
74
If 50mg of clomid don’t work yet then what do you do
Increase to 100mg of clomid
75
Causes of subfertility rates Unexplained
25% In about 40% of cases disorders are found in both man and women
76
Causes of subfertility rates Ovulatory disorders
25%
77
Causes of subfertility rates Tubal damage
20%
78
Causes of subfertility rates Factors in the male causing infertility
30%
79
Causes of subfertility rates Uterine or peritoneal disorders
10%
80
What is the general incidence of subfertility
15% - 1 in 7 heterosexual couples in the UK

Monica’s Part 2 (7 decks)

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