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P2 > Fertility > Flashcards

Fertility Flashcards

1
Q

Definition and incidence of azoospermia

A

Complete absence of spermatozoa in the ejaculate

1% all men, 10-15% infertile men

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2
Q

Obstructive causes of azoospermia

A

MC in the vas deferens epididymus or ejaculatory ducts

  • infections
  • inflammation
  • prev surgery in pelvic area
  • development of a cyst
  • hernia surgery
  • vasectomy
  • cystic fibrosis
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3
Q

Non-obstructive causes of azoospermia

A

Genetic: Kallmans, Klinefelter, Y chromosome deletion
Hormone imbalances
Retrograde ejaculation
Testicular causes:
- Anorchia
- cryptorchidism
- sertoli cell-only syndrome
- Spermatogenic arrest
- mumps orchitis
- testicular torsion
- tumours
- reaction to meds
- radiation
- chronic disease - DM, cirrhosis, renal failure
- Varicocoele

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4
Q

Diagnosing azoospermia

A

2 separate samples, examined under high-powered microscope following centrifuge spin
If first sample shows azoospermia, send repeat sample ASAP

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5
Q

NB history points wrt azoospermia

A

Fertility success/ failure
Childhood illness
Surgery/ trauma to pelvic area
Urinary/ reproductive duct tract infections
STIs
Exposure to chemo/ radio
Current/ past meds
Alcohol/ smoking/ drug use
Recent fever or exposure to heat
FHx birth defects, learning disabilities, repro failure or CF
Pituitary sx - anosmia, visual field defects, loss of libido

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6
Q

Ix in azoospermia

A

Testosterone and FSH level
Genetic testing
XR/ USS reproductive organs
Brain imaging (MRI pituitary)
Testicular biopsy

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7
Q

Management of azoospermi

A

Depends on cause

Blockage - surgery - unblock/ reconstruct
Low hormone production - HRT: FSH, HCG, clomiphene, anastrazole, letrozole
Varicocoele - surgery
Extensive biopsy for direct sperm retrieval

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8
Q

Abnormal types of findings on semen analysis

A

Asthenozoospermia - reduced mobility
Oligozoospermia - sperm concentration < 20x10^6/ml
Teratozoospermia - abnormal morphology
Hypospermia - decreased volume ejaculate
Azoospermia - no sperm in sample

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9
Q

Values looked at in semen analysis

A

Sperm volume
Sperm concentration
Total sperm count
Sperm progressive motility
Sperm morphology
SpermDNA fragmentation
Non-sperm cells

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10
Q

Normal cut off value for sperm volume and concentration

A

Volume - >1.5ml
Concentration - > 15 million/ml

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11
Q

Normal total sperm count

A

> 39 million

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12
Q

Normal sperm morphology and motility

A

Morphology > 4%
Motility > 32%

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13
Q

When to perform an HSG

A

within first 10 days of a cycle

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14
Q

CI to HSG

A

Pregnancy
Pelvic infection

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15
Q

Findings seen on HSG

A

Tubal blockage
Obstruction site
Lumen on tube
Presence of adhesions
Orientation of tubes
Hydrosalpinx
Uterine anomalies
TL reversal

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16
Q

What is salpingitis isthmica nodosa

A

AKA SIN, diverticulosis of fallopian tubes

= consequence of prev PID
- multiple small diverticular collections of contrast around tube

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17
Q

DDX salpingitis isthmica nodosa

A

Tubal TB
Endometriosis
Tubal adenomyosis

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18
Q

Risks assoc w HSG

A

Infection
Injury
Allergy to dye
Radiation exposure

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19
Q

Side effects of HSG

A

Cramps
Dizziness
Nausea
Vaginal bleeding 1-2days

20
Q

Problems with fertility in Turners syndrome

A

Common due to rapid loss of eggs in ovaries
Spontaneous pregnancy is rare - 8%
High rate of miscarriage - 40-45%
Can fall pregnant with donor eggs but increased risk

21
Q

What makes Turners patients’ pregnancies high risk

A

Developing heart vessel problems
- during pregnancy, can have aortic rupture
- 100x more likely to die during pregnancy
- vessel changes can persist post pregnancy leading to early. death in mother
NB to have cardio consult and MDT input

40-60% risk of CS due to short stature

22
Q

Contraindications to pregnancy in Turners patient

A

Aortic diameter > 35mm
Hx of aortic surgery
Uncontrolled HTN

23
Q

Impacts of smoking on reproductive health

A

Cigarette metabolites are toxic to gametes
- morphological problems with sperm
- oxidative damage at oocyte and embryo

Brings forward the age of menopause
Higher change of LBW, PTB, IUGR, SIDS
- LBW: 200% inc risk
- PTB: 50%
- miscarriage: 20-30% risk T1miscarriage

IVF - 40% less likely to conceive if ongoing smoking

24
Q

Defn POI/ POF

A

Menopause <40
Approx 1% women
0.1% <30
0.01% <20

25
Q

Modifiable risk factors for POF

A

Smoking
Chronic disease treatment

26
Q

Causes of POF

A

90% no underlying cause found; spontanous/ idiopathic
Autoimmune (5%)
- 12OH-Ab or ACA (adrenocortical antibiodies), addisons –> refer endo
- TPO Ab; TSH measured yearly
Genetic: Turners, Fragile X, Galactossaemia
Fam Hx
Infections: mumps, TB, malaria
Surgery
Cancer rx

27
Q

Investigations for POF

A

Genetic/ chromosomal:
- karyotyping –> ? Turners –> +ve: refer endo, cardio and genetics
- Test for Y chromosome material –> discuss gonadectomy
- Fra-X –> refer genetics
- Autosomal Ab testing if evidence suggesting specific mutation eg BPES
Antibodies:
- ACA/ 12OH Ab –> refer endo
TPO-Ab –> TSH testing yearly

28
Q

Signs of POF

A

Anxiety
Changes in mood
Chhanges in skin conditions
Difficultysleeping
Discomfort during intercourse
Feelings of loss of self
Hair loss of thinning
headaches or migraines
Hot flushes
Increase in facial hair
Joint stiffness
L/o self confidence
Night sweats
Palpitations
Problems w memory/. brain fog
Tinnitus
L/olibido
Recurrent UTIs
Vaginal dryness

29
Q

Diagnosing POF

A

Amenorrhoea and symptomatic

GDG recommends: Oligo/amenorrhoea for 4/12 and FSH >25 on 2 or more occasions 4 weeks apart

30
Q

Managing bone health in POF

A

Lifestyle - weight-bearing exercise, weight, diet, smoking
E replacement - reduces fractures
Bisphosphonates
COCP
DEXA - if osteo, repeat in 5 years after E

31
Q

Counselling in POF

A

Reduced life expectancy if untreated - CVS risks
Small chance of conception
Still use contraception if want to avoid pregnancy
Therapy

32
Q

HRT in POF

A

No increase in breast Ca
P for uterine protection
- ethinylestradiol + oral cyclic progesterone
Annual monitoring
Androgens - evaluated 3-6 monthly, limited to 24 months
BRCA gene - HRT conrtaindicated in BRCA survivors, carriers w BSO can have HRT
Migraines and HTN should not be a contraindication

33
Q

Definition of OHSS

A

Ovarian hyperstimulation syndrome
Complication of ART
- exposure to HCG, LH following controlled ovarian stimulation by FSH
- Production of proinflammatory markers - VEGF
- Increase vascular permeability
- loss of fluid into 3rd space –> ascites, pleural and pericardial effusions
- severe –> hypovolaemia, reduced serum osmolality and reduced sodium

34
Q

Diagnosing OHSS

A

Abdo distension and pain following trigger injection to promote final follicular maturation
Early OHSS: within 7 days of injection; excessive ovarian response
Late OHSS: >10 days post HCG injection
Symptoms: severe pain, pyrexia, peritonism
Bloods: elevated HCT, reduced osmolality, reduced sodium

35
Q

DDx of OHSS

A

Pelvic infection
Abscess
Appendicitis
Ovarian torsion
Cyst rupture
Bowel perf

36
Q

Symptoms of OHSS

A

Abdo bloating
Abdo pain
N&V
Breathlessness
Reduced urine output
Leg and vulval swelling
Assoc comorbs such as thrombosis

37
Q

NB history points wrt OHSS

A

Time of onset of symptoms relative to trigger
Med used for trigger - hcg vs GnRH agonist
Number of follicles on final monitoring scan
Number of eggs collected
Were embryos replaced and how many
PCOS diagnosis

38
Q

Defn mild OHSS

A

Abdo bloating
Mild abdo pain
Ovarian size < 8cm

39
Q

Defn mod OHSS

A

Moderate abdo pain
Nausea +/- vomiting
Ultrasound evidence of ascites
Ovarian size 8-12 cm

40
Q

Defn severe OHSS

A

Clinical ascites +/- hydrothorax
Oliguria <30ml/hr
Haematocrit >0.45
Hyponatraemia <135
Hypo-osmolality <282
Hyperkalaemia >5
Hypoproteinaemia <35
Ovarian size >12

41
Q

Critical OHSS

A

Tense ascites/ large hydrothorax
Haematocrit >0.55
WCC > 25
Oliguria/ anuria
Thromboembolism
ARDS

42
Q

Outpatient management OHSS

A

Counselling
Fluid in/out monitoring
No NSAIDS
If severe - LMWH
Paracentesis
Monitoring:
- review in 2-3 days
- baseline labs repeated if worsening
- haematocrit NB guide to the degree of intravascular depletion

43
Q

Which patients with OHSS to admit

A

Severe pain
Unable to maintain fluid intake
Worsening OHSS
Unable to attend follow up
Increasing HCT
Critical OHSS

44
Q

Inpatient management of OHSS

A

MDT if persistent haemoconcentration and dehydration
Critical –> ICU
Sx relief:
- analgesia (no NSAIDs)
- fluid replacement
- avoid diuretics
- ascites –> paracentesis
- Thrombosis –> LMWH, TEDS
Surgical management if torsion/ ectopic
If in pregnancy - incr risk of PET and PTL

45
Q
A

P2 (11 decks)

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