Fertility

Question 1

Predisposing factors OHSS

Answer 1

PCOS, high AMH, previous OHSS

Question 2

Key hx questions to ask with Ohss

Answer 2

Timing (early <7 days, late >10)
Trigger (HCG worse than LH)
Eggs (how many)
Embryo (?pregnant, often triggers late)
E2 (>4500 or >10 000)
PCOS

Question 3

Clinical manifestations OHSS + differentials

Answer 3

Differentials: pelvic infection/abscess, ectopic, bowel perforation, appendicitis, haemorrhagic cyst, torsion

Ascites, pleural effusion, pericardial effusion

LATE: renal failure, ARDS, haemorrhagic cyst rupture, VTE

Question 4

Options for unexplained infertility

Answer 4

Continue trying
Intrauterine insemination natural cycle or ovulation induction
Tubal flushing
IVF

Question 5

Male invx infert

Answer 5

Semen analysis and antibodies
If any issues on exam or at second visit
-hormone profile FSH/LH/Testosterone
-Karyotype/micro deletions
-CF testing

Question 6

Management OHSS

Answer 6

Consider admission
Daily weigh
FBC, U+E
Anti emetics
Analgesia - not ibuprofen
VTE
Supportive treatment
Consider paracentesis if symptomatic

Question 7

Causes recurrent miscarriage

Answer 7

Chromosomal - 2-5%, e.g. balanced translocation or robertsonian

APLS - 2 sets of samples, 12 weeks apart

Uterine - SM fibroid

Endocrine - PCOS/diabetes/thyroid disease

Associate=ions - BMI

DEVASTATING, give pamphlets, written info, sensitivity

Question 8

What is IVF

Answer 8

Superovulation under USS surveillance/controlled cycle
Suspend ovulation to allow
Transvaginal egg collection
Obtain sperm (?surgically)
In vitro fertilisation
Single embryo transfer on day 3-5
Luteal phase support with progesterone
Pregnancy test

Risks: OHSS, multiple pregnancy, ectopic, still may conceive spontanouesly, bloods + early dating scan

Question 9

Ashermans

Answer 9

Hysteroscopy
Break down with scope/myosure/scissors
Avoid diathermy

Given estrogen pre op and progesterone post op
Cover with abx
Increased risk of accreta

Question 10

Differentials hepatitis

Answer 10

Acute hepatitis
Autoimmune
HELLP
PET 
Gallsones
Cholestasis

Question 11

Cardiac considerations for delivery

Answer 11

Optimise iron stores
Deliver tertiary centre
Mode and timing
FLuid balance - consider IV frusemide 2nd stage
ANalgesia - epidural to override pain driven sympathomimetic increase in HR/BP
Poosition - semi recumbant/L lateral
Pushing - short 2nd w forceps
3rd stage - caution w oxytocin bolus, sudden hypotension, cause w fluid retention, ergo can cause HTN/pulmHTN/pulm oedema

Question 12

Management endometriosis for fertility

Answer 12

Benefit

• normalise anatomy
• make egg retrieval/ART easier
• improve symptoms

Risks

• Damage to ovarian reserve/blood supply
• Oophrectomy

Recommended for 3-4, less clear 1-2

Question 13

Effect of fibroids on fertility

Answer 13

Space occupying
Diversion of blood flow
Inflammatory markers

Submucousal >2cm = space effect
IM - >8cm unclear, ?operate>5cm

Question 14

Normal semen analysis

Answer 14

4% normal
40% motility
40 million
15mil per mL
at least 1.5 mL

Question 15

Age to refer to fert

Answer 15

>30 = 12/12
>35 = 6/12

From exposure, doesnt have to be actual “trying”

Question 16

Any surgery during pregnancy

Answer 16

Indication
Alternatives
ANaesthetic pre op
Pre/post monitoring/CTG
Consider steroids toco
L lateral
Senior clinician, short procedure

Question 17

Breast cancer considerations

Answer 17

Differentials - benign (fibroadenoma), abscess, lipoma, lobular hyperplasia

MDT, counselling re continuing/iatrogenic PTB
Chemo t2 onwards

Invx

• USS + core biopsy
• Consider mammogram other breast (high false neg)
• Liver USS

Aim 32/24 weeks if possible
Mastectomy, but defer recon till later

BF contralat is controversial, dw surgeon, offer dostinex
Can BF if not on chemo, need 14 day standdown

PCC - 2 year cancer free
If doxirubicin, need echo