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A - MSRA Gynaecology [8] > [19] Management of Infertility > Flashcards

[19] Management of Infertility Flashcards

1
Q

What is the first step to managing a couple with infertility?

A

Support and reassurance

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2
Q

Why is support important in infertility?

A

Can be a very difficult time with external pressure and internal emotions

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3
Q

Do most cases of infertility require intervention?

A

No

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4
Q

Why is continuous reassurance important in infertility?

A

Couples often conceive whilst being investigated and stress can impact relationship

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5
Q

What external support may be helpful for couples with infertility?

A
  • Support groups

- Counselling

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6
Q

What general advice can be given to couples with fertility problems?

A
  • Folic acid
  • Frequency of sexual intercourse
  • Alcohol
  • Smoking
  • Weight
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7
Q

What information should women with fertility issues be told regarding folic acid?

A

They should take 0.4mg/day before conception and up to 12 weeks gestation

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8
Q

Why is folic acid supplementation advised?

A

To reduce the risk of neural tube defects

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9
Q

What frequency of sexual intercourse optimises chances of conception?

A

Every 2-3 days

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10
Q

How can alcohol affect fertility in men?

A

Can affect semen quality

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11
Q

How can alcohol affect fertility in woman?

A

Advised not to when trying to conceive as can harm any developing foetus

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12
Q

How can smoking affect fertility in men?

A

Can affect semen quality

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13
Q

What advice are women given about smoking when trying to conceive?

A

Smoking can harm any developing foetus

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14
Q

What advice are women given about their weight when trying to conceive?

A

Being BMI >30 or <19 may cause conception to take longer

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15
Q

How can a mans weight affect fertility?

A

Being over weight can reduce fertility

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16
Q

How are couples with infertility less than 18 months counselled?

A

By reassurance and lifestyle changes using a ‘wait and see policy’

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17
Q

When is a ‘wait and see’ policy for infertility not recommended?

A

After 18 months and for women over 30

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18
Q

Why is a wait and see policy not recommended for women over 30?

A

Waiting may have a significant adverse impact on her lifetime chance of conception using IVF

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19
Q

Where should women over 30 with infertility be referred to?

A

Rapidly to a specialist infertility clinic that has access to a full range of assisted reproductive technologies

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20
Q

What reproductive technologies can be offered by specialist clinics?

A
  • IVF
  • ICSI
  • Intrauterine insemination
  • Donor sperm and oocyte
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21
Q

How does management of ovulation disorders vary?

A

Depending on the group of ovulation disorder

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22
Q

What advice is given to women with Group I ovulation disorders to improve their chances of conception and uncomplicated pregnancy?

A
  • Gain weight (if BMI <19)

- Moderate exercise (if undertaking high levels of exercise)

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23
Q

What treatment can be offered to women with Group I ovulation disorders?

A

Pulsatile administration of gonadotrophin releasing hormone or gonadotrophins with LH activity to induce ovulation

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24
Q

What treatment options are available for women with Group II ovulation disorders?

A
  • Clomiphene citrate
  • Laparoscopic Ovarian Diathermy
  • FSH injections
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25
Q

When is clomiphene citrate the drug of choice for Group II ovulation disorders?

A

When there is stigmata of PCOS, normal FSH and prolactin levels

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26
Q

What % of subjects will clomiphene induce ovulation in?

A

80%

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27
Q

What proportion of women who ovulate on clomiphene will be able to conceive?

A

Half

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28
Q

How is clomiphene administered?

A

From day 2-6 of the cycle with an initial dose of 50mg/day increased to 100 and 150mg/day where necessary

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29
Q

How can ovulation be measured when using clomiphene?

A

Measuring day 21 progesterone levels

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30
Q

Why may using day 21 progesterone levels to measure ovulation on clomiphene be an issue?

A

Some women will become pregnant upon resuming ovulation

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31
Q

What are the reported rates of twin pregnancy in those who fall pregnant on clomiphene?

A

6-10%

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32
Q

What monitoring is recommended when using clomiphene?

A

USS monitoring of the follicles to identify two maturing follicles

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33
Q

What is recommended if two follicles are maturing when using clomiphene?

A

Abstention from sexual intercourse

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34
Q

What is the second line intervention for Group II ovulation disorders?

A

Laparoscopic ovarian diathermy

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35
Q

What % of PCOS patients does ovarian diathermy induce ovulation in?

A

70%

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36
Q

What is the advantage of laparoscopic ovarian diathermy to induce ovulation?

A

It carries no increased risk of multiple pregnancy and is a drug-free natural conception

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37
Q

What is an alternative second line intervention to laparoscopic ovarian diathermy?

A

FSH injections

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38
Q

What are the disadvantages of FSH injections to induce ovulation?

A
  • Daily injection
  • Can be costly
  • USS and blood test monitoring is required
39
Q

What are the risks of FSH injections?

A
  • Over-response

- Multiple pregnancy

40
Q

What treatment should women with Group II ovulation disorders be offered?

A

Dopamine agonists e.g. bromocriptine

41
Q

How has the prevalence of tubal microsurgery changed as a method of managing infertility?

A

Decreased with the introduction of IVF

42
Q

When is tubal microsurgery still used?

A
  • Salpingectomy or tubal clipping prior to IVR in presence of hydrosalpynx
  • Preliminary ovarian cystectomy or myomectomy
  • Salpingolysis to release peritubal adhesions
  • Salpingostomy - blocked tubal end held open
43
Q

What risk increases following all forms of tubal surgery?

A

Risk of ectopic pregnancy

44
Q

What is a myomectomy?

A

Operation to remove fibroids

45
Q

What anaesthesia is used in a myomectomy?

A

GA

46
Q

When can a myomectomy help to manage infertility?

A

When very large fibroids are making it difficult to become pregnant or fibroids must be removed for assisted conception

47
Q

What are the risks of myomectomy?

A
  • GA risk
  • Bleeding
  • Need for hysterectomy
  • Damage to surrounding structures
48
Q

Why may a hysterectomy be needed following a myomectomy?

A

When very heavy bleeding cannot be stopped and life is at risk

49
Q

What are the potential complications of a myomectomy?

A
  • Infection
  • DVT and PE
  • Pain
  • Recurrence
50
Q

What is assisted conception?

A

Procedures whereby treated or manipulated sperm are brought into proximity with oocytes

51
Q

What are some examples of assisted conception?

A
  • Intrauterine insemination (IUI) with partner or donor sperm
  • IVF
  • Intracytoplasmic sperm injection
52
Q

What is IUI?

A

Introduction of prepared sperm into the uterine cavity around the time of ovulation

53
Q

How does ovulation occur in preparation for IUI?

A

Can be stimulated with gonadotrophins or unstimulated

54
Q

Who should unstimulated IUI be considered in?

A
  • Unable to conceive vaginally due to disability or psychosexual problems
  • Where consideration of method of conception is required e.g. male HIV
  • People in same sex relationships
55
Q

What is the physical requirement for IUI?

A

Healthy, patent fallopian tubes

56
Q

What are the live birth rates for IUI in good quality centres?

A

15-20%

57
Q

How does IUI compare to IVF in terms of cost effectiveness?

A

More cost effective

58
Q

Why is IUI more cost effective than IVF?

A
  • Lower doses of gonadotrophins
  • Reduced monitoring
  • Simplified laboratory requirements
59
Q

What % of IVF treatments result in a live birth?

A

25%

60
Q

What reduces the chance of IVF success?

A

Age of woman

61
Q

How many cycles of IV should women under 40 be offered?

A

3

62
Q

What should happen to IVF if a woman reaches 40 during treatment?

A

Current cycle should be completed then treatment withdrawn

63
Q

How many cycles of IVF are offered to women over 40?

A

1 as long as they meet criteria

64
Q

What criteria must women over 40 meet to be offered IVF?

A
  • Never had past IVF
  • No evidence of of low ovarian reserve
  • Discussed implications of IVF and pregnancy at advanced age
65
Q

How are eggs obtained in IVF?

A

Stimulation of multiple ovarian follicles using gonadotrophins and GnRH agonists/antagonists

66
Q

Why are GnRH agonists/antagonists used in IVF?

A

To prevent premature LH surge and ovulation

67
Q

How are oocytes collected for IVF?

A

Transvaginal ultrasound guided needle follicle aspiration with oocytes isolated from fluid

68
Q

How are oocytes fertilised in IVF?

A

Cultured with a washed sample of sperm

69
Q

How long are oocytes cultured for?

A

5 days to reach the blastocyst stage of division

70
Q

Why are oocytes left to reach blastocyst form?

A

So a detailed assessment of morphological quality can be made

71
Q

What is the most common obstetric problem associated with IVF?

A

Premature birth due to multiple pregnancy

72
Q

How many embryos are transferred in IVF?

A

Recommendation is of one top-quality blastocyst when available

73
Q

Why is transfer of one blastocyst recommended?

A

To reduce the risk of multiple pregnancy

74
Q

What happens to the remaining blastocysts in IVF?

A

Cryopreserved for use later if conception fails

75
Q

When may oocyte donation be appropriate?

A
  • Premature ovarian failure
  • Gonadal dysgenesis e.g. Turner syndrome
  • Bilateral oophrectomy
  • Ovarian failure following chemo or radiotherapy
  • Some cases of IVF failure
  • Where there is risk of transmitting genetic disorder
76
Q

When is it unlikely therapy will help with male infertility?

A
  • Small testes
  • Azoospermia
  • High FSH
  • Low AMH
77
Q

What is the most likely cause of male infertility if testes and FSH is normal?

A

Ductal obstruction

78
Q

What test should be performed if ductal obstruction is the suspected cause of male infertility?

A

Testicular biopsy

79
Q

What testicular biopsy result indicates likely ductal obstruction?

A

Normal spermatogenesis

80
Q

What is the treatment for ductal obstruction causing male infertility?

A

Vasography and scrotal exploration followed by surgical anastamosis

81
Q

What can help treat male infertility due to hypogonadotropic hypogonadism?

A

Gonadotrophins

82
Q

What can be given to help improve fertility of men with hyperprolactinaemia?

A

Dopamine agonists

83
Q

What are some unproven but widely practiced treatments for male infertility?

A
  • Varicocele ligation

- Supplements

84
Q

What is the most successful treatment for male infertility?

A

Intracytoplasmic Sperm Injection (ICSI)

85
Q

What happens in ICSI?

A

A single immobilised sperm is injected into the oocyte cytoplasm

86
Q

How do the pregnancy rates of ICSI compare to IVF?

A

Similar

87
Q

What is the main concern with ICSI?

A

There is a slightly higher rate of abnormality in children conceived after ICSI

88
Q

What are the main abnormalities seen in children following ICSI?

A
  • Genital tract abnormalities e.g. hypospadias, testicular maldescent
  • Imprinting disorders e.g. Angelman and Beckwith-Widemann syndromes
89
Q

When is sperm donor insemination used?

A

If sperm cannot be obtained from the partner for ICSI or the partner is a carrier for a genetic disorder

90
Q

What should be given to both parties of sperm donor insemination?

A

Independent counselling

91
Q

Is sperm donation anonymous?

A

No

92
Q

What has happened as a result of sperm donation being made non-anonymous?

A

Decrease in donation

93
Q

How is sperm (and oocyte) donation not anonymous?

A

Children can meet their genetic parent under supervised conditions after 18 years of age

A - MSRA Gynaecology [8] (52 decks)

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