fertility Flashcards
what are the different tests you may do in an infertility workup?
- Serum LH and FSH on day 2 to 5 of the cycle (checks ovarian reserve) - high FSH is bad- high LH may suggest PCOS
- Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle).- tests ovulation as the corpus leuteum will have released progesterone
- Anti-Mullerian hormone- released by granulosa cells and can tell you about ovarian reserve- can be measured at any point in the cycle
- Thyroid function tests when symptoms are suggestive- hypothyroid can lead to anovulation
- Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea
what is a normal/ good FSH level?
<9
> 20- no go
what are the different problems that may be causing infertility?
Sperm problems (30%) Ovulation problems (25%) Tubal problems (15%) Uterine problems (10%) Unexplained (20%)
what is the initial screening for fertility?
Body mass index (BMI) (low could indicate anovulation, high could indicate PCOS) Chlamydia screening Semen analysis Female hormonal testing (see below) Rubella immunity in the mother
which types of imaging can be done to investigate infertility?
- Ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus
- Hysterosalpingogram to look at the patency of the fallopian tubes
- Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometrios
what precautions should be taken before a hysterosalpingogram and why?
There is a risk of infection with the procedure, and often antibiotics are given prophylactically for patients with dilated tubes or a history of pelvic infection. Screening for chlamydia and gonorrhoea should be done before the procedure.
what percentage of couples become pregnant after 1 year of regular intercourse without contraception?
85%
what level of progesterone at day 21 indicates that ovulation has occurred?
> 30nmol/l
what progesterone level would make you want to repeat the levels?
16-30nmol/l
what progesterone level would prompt referral to a specialist?
<16
what hormonal levels indicate premature ovarian failure?
raised FSH, LH levels
e.g. FSH > 40 iu/l
low oestradiol
e.g. < 100 pmol/l
what’re management options for annovulation?
- Weight loss for overweight patients with PCOS can restore ovulation
- Clomifene may be used to stimulate ovulation
- Letrozole may be used instead of clomifene to stimulate ovulation (aromatase inhibitor with anti-oestrogen effects)
- Gonadotropins may be used to stimulate ovulation in women resistant to clomifene
- Ovarian drilling may be used in polycystic ovarian syndrome
- Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)
how can tubal factors be managed?
- tubal stents during hysterosalpingogram
- in vitro fertilisation
- laparoscopy to remove endometrial tissue or adhesions
how can sperm problems be managed?
- surgical retrieval if there is a tube blockage
- surgical correction- to fix vas deferens
- intrauterine insemination
- donor insemination
what are the hormone levels like in PCOS?
FSH- normal
LH- raised
Oestrogen- low or normal
Testosterone- raised
what test should you do to check for uterine abnormalities?
hysteroscopy
what is the mechanism of metformin in PCOS?
increases peripheral insulin sensitivity
what type of anovulation is hypogonadotrophic hypogonadal an ovulation?
hypothalamic amenorrhoea
what type of anovulation is normogonadotropic normoestrogenic anovulation?
PCOS
what type of anovulation is hypergonadotrophic hypooestrogenic anovulation?
premature ovarian insufficiency
attempts at ovulation induction are typically unsuccessful and therefore usually require in-vitro fertilisation (IVF) with donor oocytes to conceive
what is the mechanism of action of letrazole
aromatase inhibitor, reducing the negative feedback caused by estrogens to the pituitary gland, therefore increasing the amount of follicle-stimulating hormone (FSH) production and promoting follicular development
what is the mechanism of action for clomifine?
selective estrogen receptor modulator (also known as SERMs), which acts primarily at the hypothalamus, blocking the negative feedback effect of estrogens.
This subsequently leads to an increase in gonadotropin-releasing hormone (GnRH) pulse frequency and therefore FSH and LH production, stimulating ovarian follicular development
which type of anovulation is gonadotropin therapy mostly used for?
class 1 ovarian dysfunction= hypogonadotropic hypogonadism
- for women with PCOS it is only considered after weight loss, clomifine and letrazole
what happens in ovarian hyper stimulation syndrome?
ovarian enlargement with multiple cystic spaces form, and an increase in the permeability of capillaries leads to a fluid shift from the intravascular to the extra-vascular space, which has the potential to result in multiple life-threatening complications including:
- Hypovolaemic shock
- Acute renal failure
- Venous or arterial thromboembolism
how is ovarian hyper stimulation syndrome managed?
- Fluid and electrolyte replacement
- Anti-coagulation therapy
- Abdominal ascitic paracentesis
- Pregnancy termination to prevent further hormonal imbalances
how does metformin help with ovulation?
nsulin resistance -> hyperinsulinaemia -> androgen excess -> arrest in antral follicular development -> anovulation
Metformin treats insulin resistance and hyperinsulinaemia, therefore allowing follicular development and subsequent ovulation
if semen analysis is abnormal- how soon should it be repeated?
3 months
when should semen analysis be preformed?
after a minimum of 3 days and a maximum of 5 days abstinence. The sample needs to be delivered to the lab within 1 hour
