Week 5 lectures on infertility management

Question 1

What is anovulation?

Answer 1

Absence of ovulation.

Question 2

What is anovulation associated with?

Answer 2

Oligo/amenorrhoea

Question 3

What stimulates endometrial thickening?

Answer 3

FSH and oestrogen

Question 4

What do ovulation predictor kits test for?

Answer 4

The surge in LH 36 hours before ovulation.

Question 5

Where is oestrogen secreted from?

Answer 5

The developing follicle in the ovaries, the adrenal cortex and the placenta during pregnancy

Question 6

What is indicative of normal ovulation?

Answer 6

Regular 28-35 day cycles.

Confirm this by a mid luteal serum progesterone (>30nmol/L) in 2 separate samples.

Question 7

Why would you test for progesterone in the luteal phase to indicate ovulation?

Answer 7

Indicates that ovulation has passed and now the follicle has become the corpus luteum and is secreting progesterone.

Question 8

How would you treat hypogonadotrophic hypogonadism?

Answer 8

Pulsatile GnRH release- either subcutaneously or pump IV

Gonadotrophin daily injections (FSH and LH)

Question 9

What monitoring needs to be done in the treatment of hypogonadotrophic hypogonadism?

Answer 9

Ultrasound monitoring for response.

Question 10

What drug therapy can increase ovulation?

Answer 10

Clomefine citrate is an antioestrogen.

Question 11

If the first line drug therapy doesn’t work, what other drug therapies/procedures can help ovulation?

Answer 11

Metformin- decreases resistance to insulin. Also decreases androgen production.
FSH and LH daily injections
Laparoscopic ovarian drilling.

Question 12

What are the risks associated with ovulatory treatment?

Answer 12

Ovarian hyperstimulation- can vary from mild to severe.
Multiple pregnancies
Ovarian cancer.

Question 13

When are you at increased risk of developing side effects of ovulatory treatment?

Answer 13

When you are over the age of 35.

PCOS

Question 14

Symptoms of ovarian hyperstimulation

Answer 14

Mild- mild abdominal pain, ovaries greater than 8cm in size.
Moderate- abdominal pain, nausea +/- vomiting, ascites Ovarian size 8-12cm
Severe- clinical ascites, hypoproteinaemia, haematocrit>45%, ovarian size usually greater than 12cm
Critical- haematocrit>55%, oligo/anuria (painful sex), thromboembolism, ARDS

Question 15

What complications are you more likely to get with multiple pregnancies?

Answer 15

Preeclampsia, gestational diabetes, hypertension, post natal depression

Question 16

When does your risk of ovarian cancer increase?

Answer 16

If you’ve been using fertility treatments for longer than 12months.

Question 17

What is twin-twin transfusion syndrome?

Answer 17

Unbalanced vascular communications within the placental bed. Means one child (recipient) develops polyhydramnios (excessive amount of amniotic fluid) and the donor child develops oliguria (abnormally small amounts of waste product), oligohydramnios (not enough amniotic fluid) and growth restriction.

Question 18

Treatment of TTTS

Answer 18

laser division of the placental vessels, amnioreduction, septostomy.

Question 19

What are the risks associated with multiple pregnancies for the children?

Answer 19

Low birth weight and prematurity.

Question 20

What are low birth weight and prematurity linked to in the child?

Answer 20

Low IQ and ADHD.

Question 21

Short term problems of prematurity

Answer 21

40-60% require neonatal intensive care.
8% need help with breathing.
6% suffer from respiratory distress syndrome

Question 22

Long term problems of prematurity

Answer 22

In 7.4% of twin pregnancies- one child has a disability e.g. cerebral palsy, congenital heart disease and impaired site.

Question 23

How does hyperprolactinaemia present?

Answer 23

Amenorrhoea/oligomenorrhoea
Galactorrhoea (excessive or inappropriate production of breast milk)
Raised serum prolactin. Normal FSH and LH however low oestrogen.

Question 24

Medical treatment of hyperprolactinaemia?

Answer 24

Dopamine agonist.

Question 25

Define infertility

Answer 25

Failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sex in couples who have not previously conceived.

Question 26

Primary infertility

Answer 26

Couple have never had children.

Question 27

Secondary infertility

Answer 27

Couple have previously conceived (however could be failed e.g. miscarriage)

Question 28

What factors affect fertility?

Answer 28

Age BMI- 20-30 Intercourse occurring in the six days before ovulation (especially 2 days before) Alcohol consumption less than 4 units a week. Non smoker, no recreational drugs Caffiene should be less than 2 cups of coffee a day Previous pregnancy makes you more likely

Question 29

What is infertility due to?

Answer 29

Anovulatory disease- could eb anything from the hypothalamus e.g. anorexia, POF, PCOS, stress Tubal disease- infective or non infective

Question 30

Infective tubal disease

Answer 30

``` Could be pelvic inflammatory disease (chlamydia, gonorrhoea) Transperitoneal spread (appendicitis, intra-abdominal abscess) ```

Question 31

Non-infective tubal disease

Answer 31

Endometriosis, surgical (sterilisation), fibroids, polyps, congenital salpingitis isthmica.

Question 32

What is hydrosalpinx

Answer 32

Distally blocked fallopian tube filled with serous or clear fluid.

Question 33

Clinical features of hydrosalpinx

Answer 33

``` Abdominal pain Vaginal discharge Cervical excitation menorrhagia- excessive menstrual blood loss Dysmenorrhoea (painful periods) Infertility Ectopic pregnancy. ```

Question 34

What is endometriosis?

Answer 34

Presence of endometrial glands outside of the uterine cavity.

Question 35

What is the most likely cause of endometriosis?

Answer 35

Retrograde menstruation. Womb lining flows backwards into the fallopian tubes rather than out.

Question 36

Clinical features of endometriosis

Answer 36

Dysmenorrhoea (painful periods) dyspareunia (painful sex) menorrhagia (abnormally heavy periods) chronic pelvic pain

Question 37

What will a scan of endometriosis show?

Answer 37

Chocolate cysts.

Question 38

Male causes of infertility

Answer 38

Hypogonadotrophic hypogonadism e.g. Kallmanns syndrome, anorexia ect Testicular failure e.g. Kleinfelters syndrome, chemotherapy Hyperprolactinaemia (macro or micro pituitary adenoma) Acromegaly Cushings disease Hyper or hypothyroidism

Question 39

Obstructive male infertility

Answer 39

Normal sexual characteristics, normal testicular volume however vas deferens may be absent (CF). Endocrine features will show normal FSH, LH and testosterone

Question 40

Non-obstructive male infertility

Answer 40

Low testicular volume, reduced secondary characteristics, vas deferens presents. Endocrine features- high FSH and LH, low testosterone.

Question 41

What investigations would you do into male infertility?

Answer 41

History- Exam- general- look at BMI, hair distribution ect. Pelvic exam- assess for abnormalities/tenderness/mobility,

Question 42

What investigations would you do into female infertility

Answer 42

``` Endocervical swab for mucus Blood check for rubella immunity Cervical smear if due Midluteal progesterone levels (day 21 of a 28 cycle) Test of tubal patency Other tests if indicated e.g. US. ```

Question 43

What is a hysterosalpingiogram

Answer 43

Used if there are no risk factors or contraindications for using laparoscopy.

Question 44

Laparoscopy

Answer 44

Used if suspected pelvic pathology

Question 45

Hysteroscopy

Answer 45

Only performed in cases with known pathology.

Question 46

What should a normal semen analysis show

Answer 46

``` pH- 7.2-7.8 Concentration>15x10^6/ml Motility>50% Morphology>4% WBC<1x10^6 ```

Question 47

What endocrine tests would you do if semen analysis is abnormal?

Answer 47

Testosterone, FSH, LH, prolactin, thyroid function

Question 48

Why is rubella a risk in infertility?

Answer 48

Rubella or congenital rubella is a group of physical abnormalities in an infant as a result of maternal infection and subsequent feotal infection.

Question 49

Symptoms of rubella in a newborn?

Answer 49

``` Rash at birth Low birth weight Small head size Heart abnormalities Visual problems Bulging fontanelles. ```

Question 50

First line, second line and third line management of female infertility

Answer 50

1st line- clomefine citrate or tamoxifen 2nd line- GnRH daily injections 3rd line- laparoscopic ovarian drilling

Question 51

Treatment of male infertility

Answer 51

Surgery to obstructed vas deferens Intrauterine insemination in mild disease Intracytoplasmic sperm injection (sperm injected into egg) Surgical sperm aspiration from epididymis combined with ICSI Donor sperm.

Question 52

Treatment of tubal disease

Answer 52

Tubal surgery to reverse sterilisation | Success depends on amount of healthy tube.