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Gynaecology > 2: Fertility and Sub-Fertility: Causes, IVF > Flashcards

2: Fertility and Sub-Fertility: Causes, IVF Flashcards

1
Q

Define sub fertility

A

Failure to conceive despite one-year of unprotected sex, in absence of known cause infertility.

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2
Q

What is infertility

A

No possibility of conceiving

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3
Q

What is primary sub-fertility

A

When women has not conceived previously

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4
Q

What is secondary sub-fertility

A

Women has conceived previously

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5
Q

What % of couples can conceive in one-year

A

80

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6
Q

What is mnemonic to remember causes of infertility

A

UMATE

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7
Q

What are the causes of infertility

A 
Unexplained (28%)
Male (25%)
Anovulation (21%)
Tubal (20%) 
Endometriosis (8%)
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8
Q

In males, how can causes of infertility be divided

A
  • Sperm
  • Azoospermia
  • Inflammation
  • Coitus
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9
Q

What is the most-common cause of infertility in males

A

Semen abnormality

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10
Q

What proportion of infertility is due to semen abnormality

A

85%

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11
Q

What is oligospermia

A

Decrease number of sperm in ejaculate

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12
Q

What are 4 causes of oligospermia

A
  1. Testicular cancer
  2. Varicocele
  3. Alcohol
  4. Idiopathic
  5. Rec drugs
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13
Q

What proportion of male infertility is due to azoospermia

A

5%

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14
Q

Define azoospermia

A

Complete absence of sperm in ejaculate

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15
Q

How can causes of azoospermia be classified

A

Pre-testicular, Obstructive, Non-Obstructive

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16
Q

What are 3 pre-testicular causes of azoospermia

A
  • Hypogonadotorphic hypogonadism
  • Kallman’s
  • Anabolic steroids
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17
Q

What are 4 causes of obstructive azoospermia

A
  • Congenital absence vas deferens (CF)
  • Vasectomy
  • Gonorrhoea
  • Chlamydia
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18
Q

What can cause a congenital absence of the vas deferens

A

Cystic fibrosis

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19
Q

What are 3 non-obstructive causes of azoospermia

A

Klinfelter’s (XXY)
Chemotherapy
Cryptochidism
Orchitis

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20
Q

What are 3 inflammatory causes of male infertility

A
  • Antibodies = reversal vasectomy
  • Infective
  • idiopathic
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21
Q

What are coitus causes of male infertility

A

Erectile dysfunction

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22
Q

What two medications can cause erectile dysfunction

A

B-blockers

SSRIs

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23
Q

What are the 3 cause of female infertility

A
  • Anovulation
  • Tubal
  • Endometriosis
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24
Q

What are two types of anovulation

A

Primary and Secondary

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25
Q

What is primary anovulation

A

Anovulation due to pathology in the ovary

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26
Q

What are 4 causes or primary anovulation

A
  1. PCOS
  2. Tuners (45XO)
  3. Premature ovarian failure
  4. Iatrogenic: chemoradiotherapy
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27
Q

what is secondary anovulation

A

Anovulation due to problems with pituitary or hypothalamus

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28
Q

what are 5 causes of secondary anovulation

A

Kalmann’s
PCOS
Anorexia
Hyperprolactinaemia

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29
Q

What are 2 -tubal causes of female infertility

A
  1. PID

2. Previous surgery

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30
Q

Explain endometriosis as cause of infertility

A

Endometriosis causes inflammation, which can lead to scarring which can cause tubal occlusion.

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31
Q

In male ‘work-up’ for infertility what two things need to be established in history

A
  • Alcohol and Smoking = both can cause subferility

- Medications = some can lead to ED

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32
Q

On examination, what 3 aspects may be focused on

A
  1. Secondary sexual characteristics (absence of)
  2. BMI
  3. Testicular volume
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33
Q

What can obesity cause

A

Subfertility

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34
Q

What can absence of secondary sexual characteristics be caused by

A

Klinfelter’s

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35
Q

After history and examination, what should be tested in male infertility

A

Semen analysis

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36
Q

In semen analysis what do WHO define as normal progressive motility

A

32%

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37
Q

In semen analysis what do WHO define as normal total motility

A

40%

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38
Q

In semen analysis what do WHO define as normal morphology

A

> 4%

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39
Q

Why may FSH be tested for male infertility

A

Will be raised in testicular failure

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40
Q

Why may LH be tested in male infertility

A

Low in androgen deficiency

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41
Q

What karyotyping may be ordered for male infertility

A
  • Klinefelters (XXY)

- Cystic fibrosis - congenital absence VD

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42
Q

In history for female infertility what should be focused on

A

Alcohol and Smoking - Decrease fertility

Previous STI or pelvic surgery - tubal occlusion

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43
Q

What should be looked for on examination in female infertility

A 
BMI 
Hirsuitism - PCOS 
Absence secondary characteristics 
Visual field defect - prolactinoma 
Pelvic mass
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44
Q

What test is ordered to determine ovarian reserve

A

FSH

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45
Q

When should FSH be measured

A

Day 2-4 of cycle

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46
Q

What is normal for FSH

A

> 10

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47
Q

What is used to determine if individual is ovulating

A

Mid-luteal progesterone

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48
Q

When should progesterone be performed

A

7d prior to first-day menses

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49
Q

In a 28-day cycle, when should mid-luteal progesterone be performed

A

day 21

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50
Q

What level of mid-luteal progesterone indicates a women is ovulating

A

> 30

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51
Q

if a women has a mid-luteal progesterone of 16-30 what is done

A

Repeat test

52
Q

If a women has a mid-luteal progesterone of less than 16 what is done

53
Q

What is done for following mid-luteal progesterones

a. > 30
b. 16-30
c. <16

A

a. Nothing = normal
b. repeat test
c. refer

54
Q

What is gold-standard test to examine tubal latency

A

Laparoscopy and methylene blue dye

55
Q

Explain laparoscopy and dye

A

Dye is injected into cervix and laparoscopy used to examine tubal patency

56
Q

What is hysteroscopesalpingogram

A

Contrast dye injected. X-rays used to visualise

57
Q

What is hysteria-salpingo contrast sonography (HyCoSy)

A

Contrast injected, Trans-vaginal US used to examine tube patency

58
Q

What are 4 lifestyle factors in males that can improve fertility

A
  • Smoking cessation
  • Reduce alcohol
  • Medication review (If ED)
  • Weight loss if BMI over-30
59
Q

What is second-line for male infertility

A

Multivitamin

60
Q

What does the multi-vitamin given for male subfertiltiy contain

A

Zinc
Selenium
Vitamin C

61
Q

What is follow up after giving tablet containing zinc, selenium and vitamin C

A

3-months to check semen

62
Q

What is third-line for managing infertility

A

Intracytoplasmic sperm insemination (ICSI)

63
Q

What are 4 female lifestyle factors used to treat sub fertility

A
  • Smoking cessation
  • Weight loss
  • Folic acid
  • Regular sexual intercourse
64
Q

How often should a couple trying to conceive have sex

65
Q

What causes 80% of anovulation in females

66
Q

What is first-line for managing PCOS

A

Weight Loss

67
Q

What is second-line to manage sub-fertility in PCOS

A

Clomiphene citrate

68
Q

Explain how clomiphene is given

A

Day 2-6 of the cycle

69
Q

How does clomiphene work

A

It is anti-oestrogen, so works to increase FSH

70
Q

What is required in PCOS after giving clomiphene

A

US - to check for ovarian hyper stimulation

71
Q

What is third-line for managing sub-fertility in PCOS

A

Laparoscopic ovarian drilling

72
Q

What is laparoscopic ovarian drilling

A

Diathermy used to drill holes in ovary

73
Q

What is used for clomiphene-resistant PCOS

A

Gonadotrophins

74
Q

What are two indications for donor insemination

A
  • Same-sex couple (Female)

- Male has azoospermia, with abnormal semen analysis and failure of ICSI

75
Q

What is intracytoplasmic sperm injection

A

Sperm is taken from ejaculate or surgically from testes. Then injected into ova

76
Q

When is intracytoplasmic sperm injection (ICSI) used

A

IVF Failed

Abnormal sperm parameters

77
Q

What is intrauterine insemination

A

Sperm is taken form ejaculate. Or, surgically from testes and injected into uterus.

78
Q

What may intrauterine insemination be combined with

A

ovarian stimulation

79
Q

What are indications for intrauterine insemination (IUI)

A
  • Mild azoospermia
80
Q

What is in-vitro maturation

A

Immature eggs taken from ovaries and ICSI

81
Q

What is ooplasmic transfer (OT) or nuclear transfer (NT)

A

Baby has two mothers one donates ova and other cytoplasm.

82
Q

What does ooplasmic transfer count as

A

Human genetic modification

83
Q

What are 5 indications for IVF

A
  • Tubal occlusion
  • Maternal age impact fertility
  • Unexplained sub-fertility for 2-years
  • Endometriosis
  • Infertility not responding to clomiphene
84
Q

What should couples before IVF be screened for

A

HIV
Hep B
Hep C

85
Q

What are the 5 steps of IVF

A
  1. Ovarian Stimulation
  2. Oocyte retrieval
  3. Fertilisation
  4. Embryo transfer
  5. Luteal support
86
Q

What is the first-stage of IVF

A

Ovarian stimulation

87
Q

What is given in ovarian stimulation.

A

GnRH analogue or agonist

88
Q

What is the role of GnRH agonist

A

Down-regulates women HPA axis

89
Q

when is GnRH agonist given

A

Day 21 (mid-luteal) until day 10

90
Q

what is then given

91
Q

what is the role of FSH

A

Stimulate follicle development

92
Q

what is given after FSH and why

A

hCG - matures follicles

93
Q

what is the second-stage of IVF

A

Oocyte retrieval

94
Q

how long after hCG given are oocytes retrieved

95
Q

what is used to retrieve follicles

A

trans-vaginal needle aspiration

96
Q

what is stage 3 of IVF

A

fertilisation

97
Q

what is culture of sperm and oocyte referred to as

A

‘day 0’

98
Q

what days are embryos transferred into women uterus

A

2-3 or day 5 (blastocyst)

99
Q

what is the embryo at day-5

A

Blastocyst

100
Q

what is the maximum number of embryos transferred

101
Q

what is stage-5 of IVF

A

Luteal support

102
Q

what is given in stage-5

A

Progesterone

103
Q

What factors improve success of IVF

A

Younger Age
Previous pregnancy
Shorter duration sub-fertility

104
Q

What factors reduce success of IVF

A

Obese
Smoking
Low AMH

105
Q

What is role of COCP in IVF

A

Given 1-2W prior to stimulation to suppress cycle

106
Q

What is the role of gonadotrophin analogue in IVF

A

Suppresses cycles

107
Q

What is role of FSH in IVF

A

Increases follicle development

108
Q

What is role of bHCG

A

Acts a luteinising hormone surge - causing oocyte to separate from follicle

109
Q

What are both men and women given in IVF and why

A

Doxycycline - prevents infection that may impact implantation

110
Q

When should men take doxycycline

A

7d prior to retrieval

111
Q

When should women take doxycycline

A

4d prior to retrieval

112
Q

What is ovarian hyperstimulation syndrome

A

Complication of stimulation in fertilisation treatment

113
Q

What are 4 RF for ovarian hyperstimulation syndrome

A
  • Young
  • Low BMI
  • Previous OHSS
  • PCOS
114
Q

When do individuals with OHSS present with symptoms

A

5-7 after-induction

Or, 12-15d after pregnancy

115
Q

What are mild symptoms of OHSS

A

Abdominal pain

Abdominal bloating

116
Q

What are moderate symptoms of OHSS

A

Abdominal pain
Abdominal bloating
N+V
US evidence ascites

117
Q

What are severe symptoms of OHSS

A 
Abdominal pain 
Abdominal bloating 
N+V
Clinical evidence ascites 
Oliguria 
High haematocrit 
Hypoproteinaemia
118
Q

What are severe symptoms of oHSS

A 
Abdominal pain 
Abdominal bloating 
N+V
Clinical evidence ascites 
Anuria 
ARDS
VTE
119
Q

Explain pathophysiology of OHSS

A

When stimulated there can be multiple lutenised corpus luteum cysts which release oestrogen, progesterone and VEGF. VEGF causes increases in membrane permeability - accumulation fluid in pleural and peritoneal space.

120
Q

What are two features of OHSS

A

Ovarian enlargement

Fluid shift - pleural or peritoneal spaces

121
Q

What is criteria for offering IVF in women under-40

A

Offer 3-cycles of IVF if: 2-years unprotected intercourse trying to conceive with 12 cycles of artificial insemination (or 6 IUI)

122
Q

What is criteria for offering IVF in women 40-42

A

Offer 1-cycle if: 2-years unprotected intercourse or 12-cycles artificial insemination (6 IUI) and

  • No previous IVF
  • No evidence low ovarian reserve
  • Understands risk of pregnancy in this age
123
Q

What is the NHS criteria for funding IVF

A
  • No children
  • BMI <30
  • Non-smoker
  • <42
124
Q

What act regulates IVF

A

Human Fertilisation and embryology act

125
Q

Explain HFEA criteria for gamete donors

A
  • No medical or psychiatric conditions
  • Known or anonymous
  • Can only be used in up-to 10 families
  • Full infection screen
  • <35
  • Counselled
126
Q

Can children know about their donors

A

Once 18, children can contact HFEA to find-out information about their donors

Gynaecology (22 decks)

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