Fertility Flashcards
Infertility workup
Scenario 1 - 30yo BMI34, primary infertility, Hx of sexual abuse & rx Gono infection
Scenario 2 - 38yo, trying for 2 years, unable to conceive
DDx (female)
- ovu - PCOS/POI/thyroid/prl/stress/exer
- transport - PID/STI/Endo/stenosis
- implant - Ash/Sept/fibroid
- D2-4 FSH/LH/E2/AMH
- D21 P4/TFT/Prl//bHCG
- STI screen +/-CST
- Pelvic USS include AFC
- Tubal patency - HSG/HyCoSy
- +/- Lap & dye
- Semen analysis
Precon
- bloods + MCS
- vax, diet, exercise, social teratogens
AMA - don’t need to wait 12/12 before Investigation…6/12 of TTC should prompt ix
Interpretation of results
- FSH/LH/E2
- Progesterone
- TSH
- semen analysis
Menstrual cycle
- D2-4 FSH/LH/E2 - FSH <9, E2 - 25-75
- D21 P usually >20-25 = ovulation
- TSH 0.4-4.5 = normal range
- Semen analysis - 1.5ml, 15million/ml, 40%, 4%
Initial workup for male infertility
Scenario 1 - partner workup for PI, noted oligospermia 5 million
DDx
- pre-testi - Kallman (low FSH/low T)
- testi - Kleinfelter (high FSH/low T)
- post- testi - CF
Ix
- rpt SA 1-3/12 mo
- directed testing based on result
+/- FSH/LH/Karyotype/micro-Y deletion/CFTR
+/- transcrotal USS (?CBAVD)
- refer CREI
- CBAVD likely need testi bx -> ICSI
- alt - donor/adoption
Mx of tubal factor infertility
Scenario 1 - previous appendicitis -> presumably peritonism -> adhesion etc…
Scenario 2 - previous Gono infection
Scenario 3 - found to have tubal disease on routine infertility ix
Non-invasive -> HyCoSy - therapeutic
Invasive -> Diagnostic lap
- Division of adhesion
- Restore anatomy
- Dye studies patency
- Rx of co-existing pelvic pathology
- +/- salpingectomy if hydrosalpinx - ?IVF
- TTC - F/U 3-6/12 +/- CREI +/- IVF
Mx of endometriosis in the context of infertility
Scenario 1/2 - Hx of infertility, normal hormonal profile, stage IV endo with anatomical distortion, endometrioma and patent tubes/uterine cavity
- tert ref- lvl 5/6 exp endo surgeon
- endo excision improve conception rate
- re: IVF - endometrioma - access, ovarian reserve, AMH
- TTC - F/U 3-6/12 +/- CREI +/- IVF
Mx of fibroid in setting of fertility
Scenario 1 - 40yo, pre-preg ax, hx of HMB with large IMF + small SMF, hoping for UAE, partner who had vasectomy but previously fathered 2 children
Scenario 2 - 39yo, pre-preg ax, hx of HMB with large IMF c/b anemia
- risk of MC/FGR/PTL/Abruption
- expectant/med - no suitable for fertilit
- limited evidence for radiological
- UAE - ⬇️preg rate/⬆️MC/⬆️CS/PPH
- surgical - hystero resect/myomectomy
- resect SMF improve preg outcomes
- resect IMF - limited evidence
- risk of resection - Asherman’s
- risk of myomectomy - cavity breach, future MOD, hysterectomy
- written info to consider
- follow-up review
Mx of Asherman’s
Scenario 1 - amenorrheic post hysteroscopic resection of SMF
- Refer to Tert
- Unit with exp endoscopic surgeon
- Hysteroscopic adhesiolysis (Scissors)
- 1/12 of Premarin
- 10/7 of Provera induce withdraw bld
- Discuss risk of PAD in future preg
Counselling re: IVF process
- ref CREI
- +/-3-6/12 GnRH agonist
- ovulation induction
- oocyte collection
- in vitro fertilization
- embryo transfer
- risks - OHSS, multiple, ectopic
Explain how to take clomid/letrozole
Letrozole
- arthralgia/vaginal dryness/dyspareunia
Clomiphene
- hot flues, abdo discomfort, visual disturbance, multiple preg, OHSS
- pregnancy test -‘ve prior to starting
- D1 = 1st day of period
- D3-D7 letro 2.5mg or clomi 50mg
- D10-D20 intercourse every other day
- D21 (mid-luteal p4) ? ovulation
- Period - Y or N - if no then bHCG
Counselling for Carrier testing for CF
- risks pulm/panc/nutritional/longevity
- refer for genetic counseling
- test pt or pt/partner for carrier status
- 1:4 chance of CF if both carriers
Testing & Mx options if both carriers
- refer to fertility service - 3 options
1. IVF + PGD +/- CVS/amnio
2. CVS or amnio + TOP
3. Postnatal testing
Mx of OHSS
Scenario 1 - 38yo tubal factor infertility, started IVF, presented with features of OHSS
Scenario 2 - pt presents with PVB + unilateral pain post transfer for a presumed IUP of 6/40
DDx
- ovarian torsion
- ectopic pregnancy
- theca lutein cysts (risk of OI)
- appendicitis
- post procedural PID
- bowel perforation
- risk of torsion/rupture/bleed
- FBE/UEC/LFT/CRP/bHCG +/- Coag
- Pelvic USS - exclude ddx
- +/- CXR pleural effusion
- Admit + NBM - await confirm of dx
- MDI - REI +/-Med+/- Resp +/- HDU care
- Sx - analgesia/antiemetic+/-ascitic tap
- Monitor -weight/girth/UOP/bloods
- Fluid mx - PO hydrate to thirst
- +/- crystalloid +/- colloid (albumin)
- VTE prophylaxis - VTE + Clexane
- Encourage mobilization
- Feedback to ART provider
- DC criteria - sx/condition improved
- +/- VTE prophylaxis in ongoing preg
- Follow-up plan
1. Track bHCG
2. Dating scan
3. RANIx & Care
