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BMSc Human Reproduction > Female Infertility > Flashcards

Female Infertility Flashcards

1
Q

Causes of female infertility?

A

Ovulatory disorders - endocrine, iatrogenic, PCOS, anorexia, endometriosis

Tubal disorders - iatrogenic, infections, congenital, endometriosis

Uterine abnormalities

Psychosexual problems

Unexplained infertility

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2
Q

Physiological causes of anovulation?

A

Before puberty
Pregnancy
Lactation
Menopause

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3
Q

What is oligomenorrhoea?

A

Cycles >42 days (i.e. less than 8 periods/year)

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4
Q

What is amenorrhoea?

A

Absent menstruation

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5
Q

What is primary amenorrhoea?

A

Periods have never started

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6
Q

What is secondary amenorrhoea?

A

Previously have had periods but now the have stopped

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7
Q

Does oestrogen production have positive or negative feedback on pituitary/hypothalamus?

A

Both

Mainly negative feedback

However, a sustained level of oestrogen mid-cycle switched to positive feedback which drives more LH, FSH and GnRH production to stimulate ovulation

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8
Q

Does progesterone have positive or negative feedback on the pituitary/hypothalamus?

A

Negative feedback

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9
Q

What does FSH stimulate in females and when in the menstrual cycle does it increase/peak?

A

Follicular development
Thickens endometrium

Increases during follicular phase and has a small peak just before ovulation

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10
Q

What does LH stimulate in females and when in the menstrual cycle does it peak?

A

Ovulation
Development of corpus luteum
Thickens endometrium

Peaks at the LH surge 24-36 hours prior to ovulation

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11
Q

What does oestrogen do in females when in the menstrual cycle does it increase/peak?

A

Changes cervical mucus
Thickens endometrium

Increases across follicular phase and peaks before ovulation

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12
Q

What does progesterone do in females when in the menstrual cycle does it increase/peak?

A

Inhibits secretion of LH

Thickens cervical mucus
Maintains a thick endometrium
Increases basal body temperature
Relaxes smooth muscles

Peaks following ovulation in the luteal phase

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13
Q

If someone has regular cycles, are they likely to be ovulating?

A

Yes

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14
Q

If someone has irregular cycles, are they likely to be ovulating?

A

No, this is suggestive of anovulation

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15
Q

What investigation would you do to see if a woman was ovulating?

A

Midluteal serum progesterone

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16
Q

What level on a midluteal progesterone test would be suggestive of ovulation?

A

> 30 nmol/l

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17
Q

If a woman as irregular cycles, which other hormonal tests would you do?

A

FSH, LH
TSH
Prolactin
Oestrogen, testosterone, SHBG

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18
Q

What is a progesterone challenge test?

A

Administer progesterone (Provera 5mg bd) for 5 days

Progesterone levels fall after and they should experience bleeding within 7-10 days

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19
Q

What does bleeding after a progesterone challenge test indicate?

A

Shows the patient doesn’t have low oestrogen

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20
Q

What does a negative progesterone challenge test indicate?

A

Indicates that the patient either has low oestrogen levels, uterine/endometrial abnormalities or cervical stenosis

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21
Q

What are the categories of the FIGO Ovulatory Disorders Classification (2022)?

A

Type I = Hypothalamic
Type II = Pituitary
Type III = Ovarian
Type IV = PCOS

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22
Q

What are some type I (hypothalamic) causes of ovulatory disorders?

A

Stress, excessive exercise, anorexia

Brain/pituitary tumours

Head trauma

Kallmann syndrome

Drugs e.g. steroids or opioids

23
Q

What can type I ovulatory disorders also be known as?

A

Hypogonadotrophic hypogonadism
- low LH and FSH
- low oestrogen

24
Q

Levels of LH and FSH in type I ovulatory disorders are high/low?

A

Low

25
Q

Levels of oestrogen in type I ovulatory disorders are high/low?

A

Low

26
Q

Progesterone challenge test positive or negative in type I ovulatory disorders? Why?

A

Negative as low oestrogen

27
Q

What are the 2 main treatment options for type I (hypothalamic) ovulatory disorders?

A

1 - Pulsatile GnRH pumps (very expensive so not usually on NHS)

2 - Gonadotrophin daily injections e.g. Menopur (main treatment on NHS)

28
Q

Possible complication with daily gonadotrophin injections?

A

Multiple pregnancy rate is higher

29
Q

What monitoring is required when using daily gonadotrophin injections?

A

Ultrasound monitoring of the response and follicle tracking

30
Q

What are some type II (pituitary) causes of ovulatory disorders?

A

Mainly pituitary tumours releasing excess hormones

Most common cause is hyperprolactinaemia

31
Q

Levels of LH and FSH in type II ovulatory disorders are high/low?

A

Low

32
Q

Levels of oestrogen in type II ovulatory disorders are high/low?

A

Low

33
Q

Progesterone challenge test will be positive or negative in type II ovulatory disorders? why?

A

Negative as low oestrogen

34
Q

Some symptoms of hyperprolactinaemia?

A

Amenorrhoea
Galactorrhoea
Visual field problems

35
Q

How can hyperprolactinaemia be diagnosed?

A

<LH> Prolactin greater than 1000 on 2 or more occasions
MRI scan to visualise tumour
</LH>

36
Q

Treatment for hyperprolactinaemia?

A

Dopamine agonist - Cabergoline (note - stop when pregnancy occurs)

37
Q

What are some type III (ovarian) causes of ovulatory disorders?

A

Premature ovarian failure - Turners syndrome, Fragile X, autoimmune, bilateral oophorectomy, radio/chemotherapy, family history

38
Q

LH and FSH levels in type III ovulatory disorders are high/low?

A

High

39
Q

Oestrogen levels in type III ovulatory disorders are high/low?

A

Low

40
Q

What is premature ovarian failure?

A

Menopause before 40 years old

41
Q

What treatment options are there for premature ovarian failure?

A

Hormone replacement therapy (usually the COCP)

For fertility treatment egg or embryo donation is required and supportive counselling

If POF is predicted prior to chemo/radiotherapy then egg or embryo cryopreservation can be offered

42
Q

Criteria for PCOS diagnosis?

A

Rotterdam criteria - 2/3 criteria to diagnose

  • Oligo/amenorrhoea
  • Polycystic ovaries (12 or more 2-9mm follicles, increased ovarian volume >10ml)
  • Clinical/biochemical hyperandrogenism (acne, hirsutism)
43
Q

LH and FSH levels in PCOS are high/low?

A

Usually normal

44
Q

Oestrogen levels in PCOS are high/low?

A

Usually normal

45
Q

Progesterone challenge test in PCOS is usually positive/negative? Why?

A

Positive as they usually have normal oestrogen levels

46
Q

Management of PCOS for fertility?

A

1st line = Clomifene citrate or Letrozole on day 2-6 of cycle (can add in metformin)

2nd line = gonadotrophin therapy

Laparoscopic ovarian diathermy

IVF

47
Q

Main risks of ovulation induction?

A

Ovarian hyperstimulation
Multiple pregnancy
Possible increased risk of ovarian cancer

48
Q

What is ovarian hyperstimulation syndrome?

A

Exaggerated response to excess hormones

49
Q

What things can increase the risk of OHSS?

A

<35 years
PCOS

50
Q

Symptoms of OHSS?

A

Abdominal swelling
Abdominal discomfort/pain
Nausea
Vomiting
Extreme thirst and dehydration
Dark urine
Breathing difficulty
Blood clots - PE, DVT

51
Q

Infective causes of tubal disease?

A

Pelvic inflammatory disease e.g. chlamydia, gonorrhoea, syphilis, TB

Transperitoneal spread

Following a procedure e.g. IUD insertion, hysteroscopy, HSG

52
Q

Non-infective causes of tubal disease?

A

Endometriosis
Surgical sterilisation
Ectopic pregnancies
Fibroids
Congenital
Polyps

53
Q

Investigations for female infertility?

A

History
Examination
Ultrasound scan
Chlamydia screening
Cervical smear up to date
Rubella testing

Check ovulation - day 21 progesterone

Check tubes - hycosy, HSG

Other hormone tests e.g. FSH, LH, oestrogen, prolactin, thyroid function, testosterone, SHBG

BMSc Human Reproduction (11 decks)

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