female infertility Flashcards
what is primary infertility in females ?
conception has never occurred after regular unprotected sex for a year without the use of any contraception
what is secondary infertility ?
failure of conception after a previous pregnancy
6-12 months after an ectopic pregnancy
1-2 years after a full term pregnancy
what are the female causes of infertility ?
either : Anovulation Tubal diseases Endometriosis Structural/Congenital
when should we start investigating ?
only after one year OR earlier if the patient has predisposing factors age >36 Menstrual problems undescended testis viral positive prior to cancer treatment
what investigations must be done for all couples ?
semen analysis mid-luteal progesterone LH and FSH Rubella Transvaginal ultrasound Chlamydia from both partners
what tests are done for the detection of ovulation ?
basal body temperature folliculometry / ultrasonography premenstrual endometrial biopsy ( day 25) hormonal assay ( mid-luteal progesterone levels ) d21
why is serum progesterone performed in the mid luteal phase ?
progesterone is produced by the corpus leuteum
these progesterone levels peak at the mid luteal phase
what does each result of the midluteal progesterone level indicate ?
. less than 3 : anovulation
. 3-10 : poor ovulation
. more than 10 : good ovulation
what is the aetiology of tubo-peritoneal factors ?
- salpingitis, salpingo-oophoritis and pelvic peritonitis
- Chronic infection
- Pelvic endometriosis
- Uterine fibroids and ovarian cysts
- Surgical trauma
- Congenital anomalies
what are the different causes of salpingitis and pelvic peritonitis ?
STDs
puerperal and post abortive salpingitis
extension from appendicitis
which STDS must be excluded and tested for when it comes to fertility ?
gonorrhea
chlamydia
what kind of chronic infections can cause salpingitis ?
Chronic TB
or
chronic non specific PID
how can we test for tubal patency ?
laparoscopy and dye
HSG (hysterosalpingogram) X RAY
Hystero contrast sonography (US)
what is the most optimum time in relation to the menstrual cycle should a hysterosalpingogram be done ?
2 to 3 days after end of menstruation
what is the advantage of using the laparoscopic method ?
both diagnostic and therapeutic
which of the methods used to asses tubal patency should be used in a patient with co-morbidities ?
- use radiology if the patient has no co-morbidities (hysterosalpingogram or hystero contrast sonography)
- if the patient has co morbidities use laparoscope
what are the mechanisms of infertility that are due to uterine causes ?
- impairment of blastocyst implantation
- bilateral cornual obstruction of tubal ostia
- interference with transport of sperms
what is the aetiology of uterine factors ?
congenital uterine abnormalities
uterine leiomyoma
uterine polyps
intrauterine synechiae (adhesions)
what are the causes of intrauterine synechiae ?
- over curettage of basal endometrial layer ( Ashermann’s syndrome)
- acute septic endometritis
- Chronic septic infections
how cann we treat anovulation ?
medical induction of ovulation
surgical induction of ovulation ( ovarian drilling )
what are the oral drugs used for the induction of ovulation ?
- clomiphene citrate
- tamoxifen
- letrozole
what are the indications for the use of clomiphene citrate ?
anovulatory conditions with normal FSH production and intact hypothalamic pituitary axis
what diseases/conditions should clomephine citrate be used in ?
PCOD
Post pill amenorrhea
what are the side effects of clomiphene citrate ?
luteal phase defect
increased risk of twin pregnancy
ovarian hyperstimulation
what is the mechanism of action of letrozole ?
aromatase inhibitor that blocks the conversion of testosterone to oestrogen leading to increased pituitary FSH
what are the different types pituitary gonadotropins ?
- human menopausal gonadotrophins
- purified urinary FSH
- Synthetic FSH
what are the indications to using pituitary gonadotropins?
- CC resistance
- a patient with hypogonadotrophic anovulation
3 . in IVF procedures
what are the side effects of using pituitary gonadotropins ?
- ovarian hyperstimulation
2. increased risk of multiple pregnancies
what are the indications for the use of human chorionic gonadotropins ?
it is used to assist ovulation especially in CC or HMG induced cycles
what effect do different doses of GnRH have on FSH levels ?
- in small doses they increase FSH levels
- in larger preparations they first increase FSH levels followed by hypothalamic receptor down regulation which results in a decrease of FSH and LH levels
what are the combined therapies used for infertility ?
- Clomiphene citrate + human menopausal gonadotrophin +hCG ( to reduce the cost and decrease the chances of OHSS)
- GnRh/HMG/hCG
what adjuvant drugs can be used for each of these conditions :
- hyperprolactinaemia
- insulin resistance
- hypothyrididsm
- Addisons disease
- adrenogenital syndrome
- PCOS
- hyperprolactinemia - bromocriptine
- Metformin - insulin resistance
- hypothyroidism - Eltroxin
- Addison’s disease - corticosteroids
- adrenogenital syndrome - corticosteroids
- PCOS - corticosteroids
what are the cases where laparoscopic ovarian drilling can be used ?
- cases which require large doses of HMG which would cause severe OHSS
- cases that do respond to regular doses of HMG but with severe OHSS
what are the possible causes of unexplained infertility ?
- immunological and psychological factors
- defective sperm fertilization capacity
3 .decreased ovarian reserve
4 .occult cervical infection
when is myomectomy via laparotomy or laparoscopy indicated ?
in large leiomyomas that are causing infertility
what is saline infusion sonography used to diagnose ?
submucous myoma
endometrial polyps
what are the causes of post-coital bleeding ?
cervical dysplasia ectropion polyps genital tract infections vaginal atrophy
what are the consequences of a chlamydia infection ?
causes PID
salpingitis
