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Year 2 Clinical > Assessment and Management of Infertility > Flashcards

Assessment and Management of Infertility Flashcards

1
Q

Occurrence of infertility?

A

Common and half of the couples affected conceive either spontaneously or with relatively simple advice/treatment

Some remain sub-fertile and require more complex treatment, e.g: assisted conception techniques

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2
Q

Incidence of inferility increases in?

A
  • Older women (decreased fertility, increased spontaneous abortions)
  • Rise in Chlamydia infections (can cause tubule blockage)
  • Obesity (less likely to ovulate)
  • Change in expectations (same-sex marriage)
  • Awareness of treatments
  • Male factor infertility
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3
Q

Describe chances of spontaneous pregnancy

A

Increase over the months until 12 months

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4
Q

Definition of infertility?

A

Failure to achieve a clinical pregnancy after 12 months/ more of regular unprotected sexual intercourse (in absence of known reason) in a couple who have never had a child

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5
Q

2 types of infertility?

A

Primary - couple have never conceived

Secondary - couple previously conceived, although the pregnancy may not have been successful, e.g: miscarriage or ectopic pregnancy

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6
Q

Factors that increase the chance of conception?

A
  • Woman <30 years
  • Previous pregnancy
  • <3 years trying to conceive
  • If there is an unexplained cause
  • Intercourse during 6 days before ovulation, part. 2 days before ovulation
  • Woman’s BMI 20-30
  • Both partners non-smokers
  • Caffeine intake (<2 cups of coffee daily)
  • No use of recreational drugs
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7
Q

Causes of infertility in couple having IVF/ICSI?

A

Can be:

  • Unexplained
  • Tubal disease (secondary infertility is more common here)
  • Endometriosis
  • Uterine factor
  • Male factor infertility
  • Multiple factors can cause infertility

Each of these have primary and secondary sub-types

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8
Q

What is anovulatory infertility?

A

The person is infertile and their ovaries do not release an egg

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9
Q

Physiological causes of anovulatory infertility?

A

Before puberty, pregnancy, lactation and menopause

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10
Q

Gynaecological causes of anovulatory infertility?

A

Hypothalmic:

  • Anorexia/bulimia
  • Excessive exercise

Pituitary:

  • Hyperprolactinaemia
  • Tumours
  • Sheehan’s syndrome
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11
Q

Other causes of anovulatory infertility?

A

Systemic disorder, e.g: chronic renal failure

Endocrine disorder, e.g: testosterone-secreting tumours, CAH and thyroid problems

Drugs, e.g: depo-provera, explanon, OCP

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12
Q

WHO classification of anovulatory disorders?

A

Group 1 - AKA hypothalamic amenorrhea, inc:

  • Stress, excessive exercise, anorexia
  • Kallman’s syndrome
  • Isolated gonadotrophin deficiency

Group 2 - AKA hypothalamic-pituitary dysfunction; normogonadotrophic-normoestrogenic-anovulation:

• PCOS

Group 3 - AKA ovarian failure, inc. all variants of ovarian failure and resistant ovary

Other causes include hyperprolactinaemia

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13
Q

Success of ovulation induction in the different groups of ovulatory disorders?

A

Ovulation can be induced in group 1 & 2 but is usually unsuccessful in group 3 (tends to require oocyte donation)

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14
Q

Occurrence of anorexia nervosa?

A

More common in females; there is an uncertain aetiology

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15
Q

Clinical features of anorexia nervosa?

A

Low BMI (<18.5)

Loss of hair and increased lanugo (fine hair)

Low pulse and BP

Anaemia

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16
Q

Ix hormone results in anorexia nervosa?

A

Low FSH, LH and oestradiol, i.e: they develop hypogonadortrophic hypogonadism

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17
Q

Occurrence of polycystic ovary syndrome (PCOS)?

A

Most common cause of anovulatory infertility; it is an inherited condition but weight gain exacerbates it

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18
Q

Clinical features of PCOS?

A

Obesity (usually, central so waist : hip ratio is increased)

Acne/oily skin

Hirsutism

Cycle abnormalities and infertility

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19
Q

Ix biochemistry in PCOS?

A

Biochemical tests (day 2-5):

High testosterone/free androgen index

High LH

Normal oestrogen

Impaired glucose tolerance (higher risk of DM)

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20
Q

What is the diagnosis of PCOS based on?

A

Score 2 out of 3 in the Rotterdam criteria:

  • Chronic anovulation
  • Polycystic ovaries (on USS)
  • Hyperandrogenism (clinical or biochemical)
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21
Q

USS appearance of polycystic ovaries?

A

Increased ovarian volume (>10 ml)

>12 follicles, between 2-8 mm in diameter, in a single plane (a necklace pattern) and they tend to be peripherally located; can be unilateral or bilateral

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22
Q

Treatment of PCOS?

A

1st line treatment:

• Anti-oestrogens - Clomifene citrate OR Tamoxifen

2nd line treatment:

• Aromatase inhibitors - Letrozole (unlicensed)

If this fails, ask the patient to lose weight OR:

  • Clomifene citrate + Metformin (to improve sensitivity)
  • Gonadotrophin daily injections
  • Laparoscopic ovarian diathermy
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23
Q

Use of Clomifene citrate?

A

Used from days 2-6, for 5 days, with a maximum dose of 150 mcg/day; it induces ovulation in the majority of patients but only 1/2 conceive

Monitored with an ovulation tracking scan and luteal phase serum progesterone

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24
Q

Occurrence of premature ovarian failure?

A

Occurs <40 years of age, i.e: it is premature menopause (although this term is discouraged)

Can be:

  • Idiopathic
  • Genetic, e.g: Turner’s syndrome (mosaic, where 1 chromosome is normal and the other is abnormal), fragile X
  • Chemo/radiotherapy
  • Oophorectomy
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25
Q

Clinical features of premature ovarian failure?

A

Hot flushes and night sweats

Atrophic vaginitis

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26
Q

Ix hormones in premature ovarian failure?

A

High FSH and LH

Low oestradiol

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27
Q

What is tubal disease?

A

Anything that cause blockage

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28
Q

Infective causes of tubal disease?

A
  • Pelvic inflammatory disease, like STIs (e.g: chlamydia, gonorrhoea) and others (e.g: anaerobes, syphilis, TB)
  • Transperitoneal spread, e.g: appendicitis (can cause adhesions if rupture occurs), intra-abdominal abscess
  • Following procedure, e.g: IUCD insertion, hysteroscopy, HSG
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29
Q

Short-term effects of pelvic inflammatory disease?

A
  • Tubo-ovarian abscess
  • Peritonitis
  • Fitz-Hugh-Curtis syndrome - liver capsule inflammation leading to the creation of adhesions
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30
Q

Long-term effects of pelvic inflammatory disease?

A
  • Chronic pelvic pain
  • Hydrosalpinx (distally blocked fallopian tube filled with fluid) causes infertility; it creates a characteristic sausage-shaped fallopian tube and this must be operated on
  • Ectopic pregnancy
31
Q

Non-infective causes of tubal disease?

A
  • Endometriosis
  • Surgical causes (e.g: sterilisation, ectopic pregnancies)
  • Fibroids
  • Polyps
  • Congenital
  • Salpingitis isthmica nodosa (diverticulosis of the fallopian tube) - nodular thickening of narrow part of the fallopian tube due to inflammation
32
Q

Clinical features of pelvic inflammatory disease?

A
  • Abdominal/pelvic pain
  • Febrile
  • Vaginal discharge and cervical excitation
  • Dyspareunia (painful intercourse)
  • Menorrhagia (abnormally heavy or prolonged periods) and dysmenorrhea (painful periods)
  • Infertility
  • Ectopic pregnancy
33
Q

What is endometriosis?

A

Presence of endometrial glands outside the uterine cavity; incidence is higher in infertile women and it is assoc. with impaired infertility

Retrograde menstruation is the most likely cause; other inc:

  • Altered immune function
  • Abnormal cellular adhesion molecules
  • Genetic
34
Q

Clinical features of endometriosis?

A

Dysmenorrhoea (classically before menstruation) and menorrhagia

Dysparenuia and painful defaecation

Chronic pelvic pain

35
Q

Ix for endometriosis?

A

USS may show characteristic ‘chocolate’ cysts on ovary, infertility, asymptomatic; uterus may be fixed and retroverted

Histopathology shows an active, typical glandular endothelium with active proliferation and secretory changes

Laparoscopic view

36
Q

Why do chocolate cysts occur?

A

Endometrium wraps around and bleeds into the ovaries

37
Q

Male causes of infertility?

A

Hypothalmic pituitary

Testicular disease

Obstruction/transport

Unexplained

Other causes

38
Q

Endocrine causes of male infertility?

A
  1. Hypogonadotropic hypogonadism, e.g:
  • Kallmann’s syndrome
  • Anorexia
  1. Testicular failure:
  • Klinefelter’s syndrome (47 XXY)
  • Chemo/radiotherapy
  • Undescended testes
  • Idiopathic
  1. Hyperprolactinaemia (macro/microadenoma)
  2. Acromegaly
  3. Cushing’s disease
  4. Hyper/hypothyroidism
39
Q

Causes of obstructive male infertility?

A

Congenital absence e.g: in cystic fibrosis (CF)

Infection

Vasectomy

40
Q

Clinical features of obstructive male infertility?

A

Normal testicular volume

Normal secondary sexual characteristics, as sex hormones are normal

Vas deferens (normally,it is fairly muscular and can be palpated) may be absent

41
Q

Ix hormones in obstructive male infertility?

A

Normal, LH, FSH and testosterone

42
Q

Causes of non-obstructive male infertility?

A

47 XXY

Chemo/radiotherapy

Undescended tested

Idiopathic

43
Q

Clinical features of non-obstructive male infertility?

A

Low testicular volume

Reduced secondary sexual characteristics

Vas deferens will be present

44
Q

Ix hormones in non-obstructive male infertility?

A

High LH and FSH

Low oestradiol

45
Q

History questions in infertility presentation?

A

See as a couple:

  • Infertility history
  • Gynaecology
  • Andrology
  • Sexual history
  • Social history (illegal drugs/smoking)
  • PMH, PSH, POH
46
Q

Examination of a female with infertility?

A

BMI

General, assess body hair distribution and galactorrhoea

Pelvic examination (assessment for uterine and ovarian abnormalities/tenderness/mobility)

47
Q

Examination of a male with infertility?

A

BMI

General examinaion, assessing size and position of testes

Penile abnormalities

Presence of vas deferens and of any varicoceles

48
Q

Ix of a female with infertility?

A
  • Endocervical swab for chlamydia
  • Cervical smear if due
  • Blood for rubella (teratogenic) immunity
  • Mid-luteal progesterone level
  • For an anovulatory cycle, do an early menstrual hormone profile (day 2-5)
  • Test of tubal patency (with hysterosalpingiogram or laparoscopy)
  • Others if indicated: e.g. hysteroscopy, USS, endocrine profile and chromosomes
49
Q

What do regular and irregular cycle suggest and what should be done in each case?

A

Regular cycles are highly suggestive of ovulation, although some regular cycles are anovulatory; do a mid-luteal progesterone measurement

Irregular cycles usually indicate oligo/anovulation; do an early follicular hormone profile

50
Q

Treatment of an infertile female who is +ve for Chlamydia?

A

Azithromycin; if allergic, doxycycline

51
Q

How to take a mid-luteal progesterone level?

A

Take it on day 21 of a 28 day cycle OR 7 days prior to the expected period, in prolonged cycles

Progesterone > 30nmol/l suggests ovulation

52
Q

How to interpret results of blood rubella immunity test?

A

If rubella antibodies are <10 U/L, the patient is non-immune

53
Q

What is Rubella syndrome?

A

AKA congenital rubella - physical symptoms manifest in the fetus due to maternal infection; characteristics inc:

  • Rash at birth
  • Low birth weight
  • Microcephaly (small head size)
  • Heart abnormalities, e.g: patent ductus arteriosus (PDA)
  • Visual abnormalities, e.g: cataracts
  • Bulging fontanelle
54
Q

Prevention of rubella in a female attempting to conceive?

A

Rubella vaccine (MMR)

The female must not conceive in the 4 weeks following vaccination

55
Q

Treatment of tubal disease?

A

Tubal surgery - success depends on:

  • Amount of healthy tube
  • If there is both proximal and distal disease
  • Condition of tubal wall
  • Presence of adhesions

IVF

56
Q

IVF procedure?

A

On day 1 , following inseminatin, formation of 2 pro-nuclei indicates normal fertilisation

Division occurs and, on day 4, compaction occurs to form a macula; on day 5, the blastocyst forms

57
Q

What is a hysterosalpingiogram and when is it used as an Ix?

A

X-ray used to see if fallopian tubes are patent and if the uterine cavityis normal; it is indicated if there is:

  • Suspected tubal/pelvic pathology, e.g: PID, endometriosis, adhesions
  • Nil known risk factors
  • Laparoscopy contraindicated
58
Q

When is laparoscopy contraindicated?

A

Obesity, previous pelvic surgery and Crohn’s disease

59
Q

When is laparoscopy used?

A

Possible tubal/pelvic pathology, e.g: PID (pelvic inflammatory disease)

Known previous pathology, e.g: ectopic pregnancy, ruptured appendix, endometriosis

Hx suggestive of pathology, e.g: dysmerrhoea and dyspareunia

Previously abnormal HSG

60
Q

What is a hysteroscopy and when is it used?

A

Examinate the uterine cavity; ONLY performed in cases where suspected or known endometrial pathology, i.e: uterine septum, adhesions, polyp

61
Q

When is a pelvic USS used?

A

When: • Abnormality on pelvic examination, e.g: enlarged uterus, adnexal mass • Required from other Ix, e.g: possible polyp seen at HSG

62
Q

Other assessments that can be done if the patient has an anovulatory cycle or infrequent periods?

A
  • Urine HCG (pregnancy test)
  • Prolactin
  • TSH
  • Testosterone and SHBG (sex-hormone binding globulin)
  • LH, FSH and oestradiol
63
Q

Other assessment that can be done if the patient has hirsutes?

A

Testosterone and SHBG

64
Q

Other assessments that can be done if the patient has amenorrhea?

A

• Endocrine profile • Karyotype

65
Q

Treatment of premature menopause?

A

Counselling and prevention of osteoporosis

Oocyte donation

Cryopreservation of ovarian tissue (prior to radiotherapy/therapy)

66
Q

Causes of male factor infertility?

A

Mostly idiopathic

Obstructive causes

Non-obstructive causes

Hormonal causes

Others: varicocele, chemotherapy, radiotherapy erectile dysfunction, immunological

67
Q

Obstructive causes of male infertility?

A

Vasectomy

Infection (e.g: chlamydia/gonorrhoea)

Congenital absence of vas deferens (e.g: CF)

68
Q

Non-obstructive causes of male infertility?

A

Undescended testis

Orchitis (e.g: mumps)

Torsion/trauma

Chromosomal, e.g: Klinefelter’s syndrome (47XXY), Kartagener syndrome, Y-chromosome micro deletions

69
Q

Hormonal causes of male infertility?

A
  • Hypogonadotrophic hypogonadism
  • Hypothyroidism
  • Hyperprolactinaemia
  • Testicular cancer
70
Q

Ix of a male with infertility?

A

Semen analysis; this is done twice but over 6 weeks apart:

  • If abnormal, do an endocrine profile
  • If severely abnormal / azoospermic, do an endocrine profile + chromosome analysis and screen for CF
71
Q

Normal semen parameters on analysis?

A

Volume >1.5 ml

pH 7.2-7.8

Concentration >15x10 to the power of 6 /ml

Morphological normal forms of 4%

Motility - >50%

WBC - 1x10 to the power of 6 /ml

72
Q

What Ix should be done in a male that has an abnormality on genital examination?

A

Scrotal USS

73
Q

Treatment of male infertility?

A

Surgery to obstructed vas deferens

Intra-uterine insemination (in mild disease)

Intra-cytoplasmic sperm injection (ICSI)

Percutaneous Epididymal Sperm Aspiration (PESA), combined with ICSI OR Percutaneous Testicular Sperm Aspiration

Donor sperm insemination

Year 2 Clinical (119 decks)

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