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Obs+Gynae+Repro > Fertility > Flashcards

Fertility Flashcards

1
Q

When should a couple be referred for investigation for infertility?

A

couple has been trying to conceive without success for 12 months
reduced to 6 months if the woman is older than 35 years (ovarian stores are likely to be already reduced and time is more precious)

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2
Q

What are the causes of infertility?

A

sperm problems (30%)
ovulation problems (25%)
tubal problems (15%)
uterine problems (10%)
unexplained (20%)

40% of couples have a mix of causes

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3
Q

What general advice should be given to couples trying to conceive?

A

woman should be taking 400mcg folic acid daily
aim for a healthy BMI
avoid smoking and drinking excessive alcohol
reduce stress (may negatively affect libido and relationship)
aim for intercourse every 2-3 days
avoid timing intercourse (not necessary and can lead to increased stress and pressure)

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4
Q

What initial investigations for infertility can be performed in primary care?

A

BMI (low could indicate anovulation, high could indicated PCOS)
chlamydia screening
semen analysis
female hormonal testing
rubella immunity in the mother

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5
Q

What is involved in female hormonal testing for infertility in primary care?

A

serum LH and FSH on day 2-5 of cycle
serum progesterone on day 21 of the cycle or 7 days before the end of the cycle if not a 28 day cycle
anti-Mullerian hormone
TFTs (if symptoms are suggestive)
prolactin when symptoms of galactorrhoea or amenorrhoea

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6
Q

What do the results of female hormonal testing for infertility in primary care suggest?

A

high FSH = poor ovarian reserve (pituitary gland is producing extra FSH in an attempt to stimulate follicular development)
high LH = PCOS
rise in progesterone on day 21 = ovulation has occurred
anti-Mullerian hormone = measures ovarian reserve - high level indicates a good reserve

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7
Q

What investigations for female infertility can be carried out in secondary care?

A

US pelvis - look for polycystic ovaries or any structural abnormalities in the uterus
hysterosalpingogram - look at patency of the fallopian tubes
laparoscopy and dye test - look at patency of the fallopian tubes, adhesions and endometriosis

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8
Q

What is the management of anovulation?

A

weight loss

stimulate ovulation:
1st line = clomifene
2nd line = letrozole
3rd line = gonadotropins

ovarian drilling in PCOS

metformin if insulin insensitivity and obestiy

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9
Q

What is the MOA of clomifene?

A

anti-oestrogen - selective oestrogen receptor modulator
given on days 2-6 of cycle to stop negative feedback of oestrogen on the hypothalamus - results in greater GnRH release and subsequently FSH and LH

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10
Q

What is the MOA of letrozole?

A

aromatase inhibitor with anti-oestrogenic effects

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11
Q

What is the management of tubal factor infertility?

A

tubal cannulation during a hysterosalpingogram
laparoscopy to remove adhesions or endometriosis
IVF

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12
Q

What is the management of uterine factor infertility?

A

surgery to correct polyps, adhesions or structural abnormalities

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13
Q

What are the instructions for providing a semen sample?

A

abstain from ejaculation for at least 3 days and at most 7 days
avoid hot baths, sauna and tight underwear during the lead up to providing a sample
attempt to catch the full sample
deliver the sample to the lab within 1 hrs of ejaculation
keep the sample warm (e.g. in underwear) before delivery

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14
Q

What factors can affect semen analysis and sperm quality and quantity?

A

hot baths
tight underwear
smoking
alcohol
raised BMI
caffeine

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15
Q

When is a repeat semen sample indicated?

A

3 months in borderline results
2-4 weeks in very abnormal resutls

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16
Q

What are the normal semen analysis results?

A

semen volume >1.5ml
semen pH >7.2
concentration of sperm >15 million per ml
total number of sperm >39 million per sample
>40% of sperm are mobile
>58% of sperm are active
>4% of sperm are normal

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17
Q

What is polyspermia/polyzoospermia?

A

high number of sperm in the semen - >250 million per ml

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18
Q

What is normospermia/normozoospermia?

A

normal characteristics of sperm

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19
Q

What is oligospermia/oligozoospermia?

A

reduced number of sperm in semen sample

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20
Q

What is mild oligospermia?

A

10-15 million sperm per mil

21
Q

What is moderate oligospermia?

A

5-10 million sperm per mil

22
Q

What is severe oligospermia?

A

<5 million sperm per ml

23
Q

What is cryptozoospermia?

A

very few sperm in the semen sample - <1 million/ml

24
Q

What is azoospermia?

A

absence of sperm in the semen

25
Q

What are the pre-testicular causes of male infertility?

A

hypogonadotrophic hypogonadism (low LH and FSH resulting in low testosterone):
pathology of the pituitary gland or hypothalamus
suppression due to stress, chronic conditions or hyperprolactinaemia
Kallman syndrome

26
Q

What are the testicular causes of male infertility?

A

testicular damage = mumps, undescended testes, trauma, radiotherapy, chemotherapy, cancer

genetic or congenital disorders that result in defective or absent sperm production = Klinefelter syndrome, Y chromosome deletions, Sertoli cell-only syndrome, anorchia (absent testes)

27
Q

What are the post-testicular causes of male infertility?

A

damage to the testicle or vas deferens from trauma, surgery or cancer
ejaculatory duct obstruction
retrograde ejaculation
scarring from epididymitis
absence of vas deferens (may be associated with cystic fibrosis)
Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)

28
Q

What are the management options of male infertility?

A

surgical sperm retrieval where there is obstruction
surgical correction of an obstruction in the vas deferens
intra-uterine insemination = separating high-quality sperm and injecting them into the uterus
intracytoplasmic sperm injection = injecting sperm directly into the cytoplasm of an egg
donor insemination

29
Q

What is the success rate of each IVF attempt at producing a live birth?

A

25-30%

30
Q

How many cycles of IVF are couples offered on the NHS?

A

3

31
Q

What are the criteria for couples to be offered IVF on the NHS?

A

co-habiting in a stable relationship for a minimum of two years
both must be non-smoking for at least 3 months before treatment and continue to be non-smoking during treatment
both must abstain from illegal and abusive substances
both must be methadone free for at least one year prior to treatment
neither partner should drink alcohol prior to or during the period of treatment
BMI of female partner must be above 18.5 and below 30
neither partner to have undergone voluntary sterilisation, even if it has been reverse
neither partner has already received 3 IVF cycles
fresh cycles must be initiated before the female’s 40th birthday and frozen transfers must be initiated before the female’s 41st birthday

32
Q

What are the steps involved in the process of IVF?

A

suppressing the natural menstrual cycle
ovarian stimulation
oocyte collection
insemination/intracytoplasmic sperm injection
embryo culture
embryo transfer

33
Q

What are the two protocols for suppression of the natural menstrual cycle for IVF?

A

GnRH agonists
GnRH antagonists

34
Q

How can GnRH agonists be used to suppress the natural menstrual cycle?

A

injection of GnRH agonist (e.g. goserelin) given during the luteal phase of the menstrual cycle around 7 days before the expected onset of the menstrual period (usually day 21 of cycle)
initially stimulates the pituitary gland to secrete a large amount of LH and FSH
after this initial surge, there is negative feedback to the hypothalamus and the natural production of GnRH is suppressed causing suppression of the menstrual cycle

35
Q

How can GnRH antagonists be used to supress the natural menstrual cycle?

A

daily SC injections of a GnRH antagonist (e.g. cetrorelix) starting from day 5-6 of ovarian stimulation
suppresses LH release

36
Q

How are the ovaries stimulated for IVF?

A

SC injections of FSH from day 2 of cycle for 10-14 days
when enough follicles have developed to an adequate size, the FSH is stopped and an injection of hCG is given to mature the follicles
eggs are collected 36hrs later

37
Q

When are embryos implanted in IVF?

A

days 2-5

38
Q

When is a pregnancy test performed in IVF?

A

around day 16

39
Q

What is used from the time of oocyte collection until 8-10 weeks gestation in IVF?

A

progesterone vaginal suppositories to mimic corpus luteum

40
Q

What are the complications of IVF?

A

failure
multiple pregnancy
ectopic pregnancy
ovarian hyperstimulation syndrome

41
Q

What are the potential complications of the egg collection procedure?

A

pain
bleeding
pelvic infection
damage to the bladder or bowel

42
Q

What are the risk factors of ovarian hyperstimulation syndrome (OHSS)?

A

younger age
lower BMI
raised anti-Mullerian hormone
higher antral follicle count
PCOS
raised oestrogen levels during ovarian stimulation

43
Q

How are women monitored to determine risk of OHSS?

A

during stimulation with gonadotropins:
serum oestrogen levels - higher levels = higher risk
US monitor of follicles - higher number and larger size = higher risk

44
Q

What can be done to reduce the risk of OHSS in women at higher risk?

A

use of GnRH antagonist protocol (rather than GnRH agonist protocol)
lower doses of gonadotropins
lower dose of the hCG injection
alternatives to hCG injection (e.g. a GnRH agonist or LH)

45
Q

When does OHSS present?

A

early = within 7 days of hCG injection
late = after 10 days from hCG injection

46
Q

What are the features of OHSS?

A

abdominal pain and bloating
nausea and vomiting
diarrhoea
hypotension
hypovolaemia
ascites
pleural effusions
renal failure
peritonitis (from rupturing follicles releasing blood)
prothrombotic state (risk of DVT and PE)

47
Q

What is the management of OHSS?

A

supportive with treatment of any complications:
oral fluids
monitor urine output
LMWH to prevent VTE
ascitic fluid removal
IV colloids (e.g. human albumin solution)

48
Q

What are the features of Kartagener’s syndrome?

A

dextrocardia or complete situs inversus
bronchiectasis
recurrent sinusitis
subfertility

49
Q

What is the pathogenesis of Kartagener’s syndrome?

A

dynein arm defect results in immotile cilia

Obs+Gynae+Repro (9 decks)

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