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YEAR 4- OBSTETRICS > Fertility > Flashcards

Fertility Flashcards

1
Q

Define Infertility.

A

Failure to conceive after frequent unprotected sexual intercourse for one or two years.

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2
Q

What is considered frequent sex?

A

Every 2-3 days

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3
Q

What are the 2 types of infertility.

A

Primary infertility
Secondary infertility.

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4
Q

Define primary infertility

A

Never been pregnant

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5
Q

Define secondary infertility

A

Have experienced a previous pregnancy (including ectopic and those terminated) but are struggling to conceive again now.

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6
Q

What is subfertility?

A

Any form of reduced fertility that results in a prolonged duration of lack of conception.

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7
Q

What percentage of couples will conceive naturally within 1 year with regular unprotected intercourse?

A

84%

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8
Q

Male causes of infertility can be divided into 3 categories.

State the 3 categories.

A

1-Pre-testicular
2-Testicular
3-Post-testicular

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9
Q

Suggest 3 pre-testicular causes of male infertility.

A

1-Diabetes
2-Erectile dysfunction
3-Hyperprolactinemia

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10
Q

Suggest 3 testicular causes of male infertility.

A

1-Testicular torsion
2-Klinefelter syndrome (XXY)
3-Irradiation/drugs

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11
Q

Suggest 3 post-testicular causes of male infertility.

A

1-Vasectomy
2-Sexual dysfunction
3-Infective

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12
Q

Female causes of infertility can be divided into 3 categories. State the 3 categories.

A

1- Ovulatory disorders
2-Uterine and peritoneal disorders
3-Tubal damage

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13
Q

Ovulatory disorders are anything which interferes with or stops ovulation.
Suggest 3 ovulatory disorders which can cause infertility.

A

1-Polycystic ovarian syndrome
2-Hyperprolactinaemic amenorrhoea
3-Premature ovarian failure
4-Turners syndrome (45XO)

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14
Q

Ovulatory disorders are anything which interferes with or stops ovulation.
Suggest 3 ovulatory disorders which can cause infertility.

A

1-Polycystic ovarian syndrome
2-Hyperprolactinaemic amenorrhoea
3-Premature ovarian failure
4-Turners syndrome (45XO)

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15
Q

Uterine and peritoneal disorders are physical reasons why implantation fails.
Suggest 3 uterine and peritoneal disorders which can cause infertility.

A

1-Uterine fibroids
2-Endometriosis
3-Pelvic inflammatory disorder (causes scarring/adhesions)

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16
Q

Tubal disorders are conditions which affect the Fallopian tubes and disrupt the transport of the ovum.
Suggest 3 tubal disorders which cause infertility.

A

1-Endometriosis
2-Ectopic pregnancy
3-Pelvic inflammatory disorder
4-Pelvic surgery

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17
Q

When would you refer a couple to secondary care/ infertility specialists?

A

If history, examination and investigations are normal in BOTH partners and they have NOT conceived after 1 year.

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18
Q

State 2 reasons when you would consider early referral to secondary care/ infertility specialists?

A

1-If there is a known infertility cause
2-In women older than 35 years, after 6 months of not conceiving

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19
Q

Suggest 6 pieces of general advice you should give to couples trying to conceive.

A
  • The woman should be taking 400mcg folic acid daily
  • Aim for a healthy BMI
  • Avoid smoking and drinking excessive alcohol
  • Reduce stress as this may negatively affect libido and the relationship
  • Aim for intercourse every 2 – 3 days
  • Avoid timing intercourse
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20
Q

Initial investigations can be performed in primary care.

Suggets 4 initial investigations for infertility.

A
  1. Body mass index (BMI) (low could indicate anovulation, high could indicate PCOS)
  2. Chlamydia screening
  3. Semen analysis
  4. Female hormonal testing (see below)
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21
Q

What does female hormone testing involve?

A
  • Serum LH and FSH
  • Serum progesterone
  • Anti-Mullerian hormone
  • Thyroid function tests
  • Prolactin
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22
Q

Further investigations are often performed in secondary care after referral to specialists.
Suggest 3 further investigations for infertility.

A
  1. Ultrasound pelvis (of female)
  2. Hysterosalpingogram
  3. Laparoscopy and dye test
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23
Q

Why is a ultrasound of the pelvis performed?

A

To look for polycystic ovaries or any structural abnormalities with the uterus.

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24
Q

What is a Hysterosalpingogram and why is it performed?

A

What-A small tube is inserted into the cervix. A contrast medium is injected through the tube and fills the uterine cavity and fallopian tubes. Xray images are taken, and the contrast shows up on the xray giving an outline of the uterus and tubes. If the dye does not fill one of the tubes, this will be seen on an xray and suggests a tubal obstruction.

Why-to assess the shape of the uterus and the patency of the fallopian tubes.

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25
Q

What is the laparoscopy and dye test and why is it performed?

A

What-The patient is admitted for laparoscopy. During the procedure, dye is injected into the uterus and should be seen entering the fallopian tubes and spilling out at the ends of the tubes.

Why-the surgeon can assess for endometriosis or pelvic adhesions and treat these. As well as looking at fallopian tube patency with the dye.

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26
Q

What is anovulation?

A

Anovulation is when the ovaries do not release an oocyte during a menstrual cycle. I.e. There is no ovulation.

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27
Q

What drug can be used to stimulate ovulation and how does it work?

A

Clomifene
* Clomifene is an anti-oestrogen (a selective oestrogen receptor modulator).
* It is given on days 2 to 6 of the menstrual cycle.
* It stops the negative feedback of oestrogen on the hypothalamus, resulting in a greater release of GnRH and subsequently FSH and LH.

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28
Q

Ovarian drilling can be used when PCOS is the cause of anovulation.

What is Ovarian drilling?

A
  • Ovarian drilling involves laparoscopic surgery.
  • The surgeon punctures multiple holes in the ovaries using diathermy or laser therapy.
  • This can improve the woman’s hormonal profile and result in regular ovulation and fertility.
29
Q

Suggest 3 options for women who have abnormalities with their fallopian tubes which is causing their infertility.

A
  1. Tubal cannulation during a hysterosalpingogram to open up the fallopian tubes
  2. Laparoscopy to remove adhesions or endometriosis
    3.In vitro fertilisation (IVF)
30
Q

Semen analysis is used to examine the quantity and quality of semen and sperm.
It is used to assess for male infertility.

Suggest 5 pieces of advice which should be given to a man who is giving a semen sample.

A
  1. Abstain from ejaculation for at least 3 days and at most 7 days
  2. Avoid hot baths, sauna and tight underwear during the lead up to providing a sample
  3. Attempt to catch the full sample
  4. Deliver the sample to the lab within 1 hour of ejaculation
  5. Keep the sample warm (e.g. in underwear) before delivery
31
Q

Suggets 5 factors which can affect the quality of sperm?

A
  1. Hot baths
  2. Tight underwear
  3. Smoking
  4. Alcohol
  5. High BMI
32
Q

What factors are assessed in semen analysis?

A
  • Semen volume (more than 1.5ml)
  • Semen pH (greater than 7.2)
  • Concentration of sperm (more than 15 million per ml)
  • Total number of sperm (more than 39 million per sample)
  • Motility of sperm (more than 40% of sperm are mobile)
  • Vitality of sperm (more than 58% of sperm are active)
  • Percentage of normal sperm (more than 4%)
33
Q

What does the term Polyspermia mean?

A

A high number of sperm in the semen sample

34
Q

What does the term Normospermia mean?

A

Refers to normal characteristics of the sperm in the semen sample.

35
Q

What does the term Oligospermia mean?

A

A reduced number of sperm in the semen sample.

36
Q

Oligospermia is further subclassified into what categories?

A
  • Mild oligospermia (10 to 15 million / ml)
  • Moderate oligospermia (5 to 10 million / ml)
  • Severe oligospermia (less than 5 million / ml)
37
Q

What does the term Cryptozoospermia mean?

A

Refers to very few sperm in the semen sample
(less than 1 million / ml)

38
Q

What is Azoospermia?

A

The absence of sperm in the semen.

39
Q

Suggest 3 pre-testicular causes of infertility.

A
  1. Pathology of the pituitary gland or hypothalamus
  2. Suppression due to stress, chronic conditions or hyperprolactinaemia
  3. Kallman syndrome
40
Q

Suggest how pre-testicular causes can result infertility.

A
  • Testosterone is necessary for sperm creation.
  • The hypothalamo-pituitary-gonadal axis controls testosterone.
  • Hypogonadotrophic hypogonadism (low LH and FSH resulting in low testosterone).
  • This can be caused by things such a pathology in the pituitary gland or hypothalamus.
41
Q

Suggets 5 testicular causes of infertility.

A
  1. Mumps
  2. Undescended testes
  3. Trauma
  4. Radiotherapy
  5. Chemotherapy
  6. Cancer
42
Q

What are post-testicular causes of infertility.

A

Things which result in obstruction preventing sperm being ejaculated.

43
Q

Give 4 causes of post testicular infertility.

A
  1. Damage to the testicle or vas deferens from trauma, surgery or cancer
  2. Ejaculatory duct obstruction
  3. Retrograde ejaculation
  4. Scarring from epididymitis, for example, caused by chlamydia
44
Q

Patients with abnormal semen results are referred to a urologist for further investigations.

Suggest 4 further investigations.

A
  1. Hormonal analysis with LH, FSH and testosterone levels
  2. Genetic testing
  3. Further imaging, such as transrectal ultrasound or MRI
  4. Vasography, which involves injecting contrast into the vas deferens and performing xray to assess for obstruction
45
Q

Managment for abnormal semen analysis depends on the cause

Suggest 2 management options for obstructive causes e.g. post testicular causes.

A

Surgical sperm retrieval where there is obstruction

Surgical correction of an obstruction in the vas deferens

46
Q

What is surgical sperm retrieval?

A

When there is a blockage somewhere along the vas deferens preventing sperm from reaching the ejaculated semen.
A needle and syringe is used to collect sperm directly from the epididymis through the scrotum.

47
Q

What is Intra-uterine insemination?

A

Intra-uterine insemination involves collecting and separating out high-quality sperm, then injecting them directly into the uterus to give them the best chance of success. It is unclear whether this is any better than normal intercourse.

48
Q

What is Intracytoplasmic sperm injection (ICSI)?

A

Injecting sperm directly into the cytoplasm of an egg. These fertilised eggs become embryos, and are injected into the uterus of the woman.

This is useful when there are significant motility issues, a very low sperm count and other issues with the sperm.

49
Q

What is Donor insemination?

A

Sperm from a donor is another option for male factor infertility.

50
Q

What is IVF?

A
  • In vitro fertilisation involves fertilising an egg with sperm in a lab
  • Then injecting the resulting embryo into the uterus.
51
Q

IVF is a complicated and expensive process. As a reuslt the referral criteria is very strict.

What is the success rate of producing a live birth?

A

25-30%

52
Q

What are the 6 basic steps of IVF?

A
  1. Suppressing the natural menstrual cycle
  2. Ovarian stimulation
  3. Oocyte collection
  4. Insemination / intracytoplasmic sperm injection (ICSI)
  5. Embryo culture
  6. Embryo transfer
53
Q

What happens in the suppressing the natural menstrual cycle stage using GnRH agonists?

A
  • An injection of a GnRH agonist (e.g. goserelin) is given in the luteal phase of the menstrual cycle, around 7 days before the expected onset of the menstrual period (usually day 21 of the cycle).
  • This initially stimulates the pituitary gland to secrete a large amount of FSH and LH.
  • However, after this initial surge in FSH and LH, there is negative feedback to the hypothalamus, and the natural production of GnRH is suppressed.
  • This causes suppression of the menstrual cycle.
  • Without suppression of the natural gonadotropins (LH and FSH), ovulation would occur and the follicles that are developing would be released before it is possible to collect them.
54
Q

What happens in the suppressing the natural menstrual cycle stage using GnRH antagonist?

A
  • For the GnRH antagonist protocol, daily subcutaneous injections of a GnRH antagonist (e.g. cetrorelix) are given, starting from day 5 – 6 of ovarian stimulation.
  • This suppresses the body releasing LH and causing ovulation to occur.
  • Without suppression of the natural gonadotropins (LH and FSH), ovulation would occur and the follicles that are developing would be released before it is possible to collect them.
55
Q

What happens in the ovarian stimulation stage?

A
  • Ovarian stimulation involves using medications to promote the development of multiple follicles in the ovaries.
  • This starts at the beginning of the menstrual cycle (usually day 2), with subcutaneous injections of FSH over **10 to 14 days. **
  • The FSH stimulates the development of follicles, and this is closely monitored with regular transvaginal ultrasound scans.
  • When enough follicles have developed to an adequate size (usually around 18 millimetres), the FSH is stopped, and an injection of human chorionic gonadotropin (hCG) is given.
  • This injection of HCG is given 36 hours before collection of the eggs.
  • The hCG works similarly to how LH does naturally, and stimulates the final maturation of the follicles, ready for collection.
  • This is referred to as a “trigger injection”.
56
Q

What happens in the oocyte collection stage?

A
  • The oocytes (eggs) are collected from the ovaries under the guidance of a transvaginal ultrasound scan.
  • A needle is inserted through the vaginal wall into each ovary to aspirate the fluid from each follicle.
  • This fluid contains the mature oocytes from the follicles.
  • The procedure is usually performed under sedation (not a general anaesthetic).
  • The fluid from the follicles is examined under the microscope for oocytes.
57
Q

What happens in the insemination stage?

A
  • After the eggs are harvested, and a semen sample is produced, the highest quality sperm are isolated and injected directly into the cytoplasm of the egg.
  • The male produces a semen sample around the time of oocyte collection.
  • Frozen sperm from earlier samples may be used.
  • The sperm and egg are mixed in a culture medium. Thousands of sperm need to be combined with each oocyte to produce enough enzymes (e.g. hyaluronic acid) for one sperm to penetrate the corona radiata and zona pellucida and fertilise the egg.
58
Q

What happens in the embryo culture stage?

A
  • Dishes containing the fertilised eggs are left in an incubator and observed over 2 – 5 days to see which will develop and grow.
  • They are monitored until they reach the blastocyst stage of development (around day 5).
59
Q

What happens in the embryo transfer stage?

A
  • After 2 – 5 days, the highest quality embryos are selected for transfer.
  • A catheter is inserted under ultrasound guidance through the cervix into the uterus.
  • A single embryo is injected through the catheter into the uterus, and the catheter is removed.
  • Generally, only a single embryo is transferred.
  • Two embryos may be transferred in older women (i.e. over 35 years).
  • Any remaining embryos can be frozen for future attempts at transfer.
60
Q

When is a pregnancy test performed in the IVF cycle?

A

16 days after embryo transfer

61
Q

Is there still possibility of ectopic or misscarriage with IVF?

A

Yes

62
Q

Suggest 4 complications of IVF?

A
  1. Failure
  2. Multiple pregnancy
  3. Ectopic pregnancy
  4. Ovarian hyperstimulation syndrome
63
Q

Suggest 4 complications of egg collection?

A
  1. Pain
  2. Bleeding
  3. Pelvic infection
  4. Damage to the bladder or bowel
64
Q

What is Ovarian hyperstimulation syndrome?

A

Ovarian hyperstimulation syndrome (OHSS) is a complication of ovarian stimulation during IVF infertility treatment.
It is associated with the use of human chorionic gonadotropin (hCG) to mature the follicles during the final steps of ovarian stimulation.

65
Q

Explain the pathophysiology of ovarian hyperstimulation syndrome?

A

The primary mechanism for OHSS is an increase in vascular endothelial growth factor (VEGF) released by the granulosa cells of the follicles. VEGF increases vascular permeability, causing fluid to leak from capillaries. Fluid moves from the intravascular space to the extravascular space. This results in oedema, ascites and hypovolaemia.

The use of gonadotrophins (LH and FSH) during ovarian stimulation results in the development of multiple follicles. OHSS is provoked by the “trigger injection” of hCG 36 hours before oocyte collection. HCG stimulates the release of VEGF from the follicles. The features of the condition begin to develop after the hCG injection.

66
Q

Suggets 6 risk factors for ovarian hyperstimulation syndrome?

A
  • Younger age
  • Lower BMI
  • Raised anti-Müllerian hormone
  • Higher antral follicle count
  • Polycystic ovarian syndrome
  • Raised oestrogen levels during ovarian stimulation
67
Q

Early OHSS presents within 7 days of the hCG injection. Late OHSS presents from 10 days onwards.

Suggest 8 features of Ovarian hyperstimulation syndrome.

A
  1. Abdominal pain and bloating
  2. Nausea and vomiting
  3. Diarrhoea
  4. Hypotension
  5. Hypovolaemia
  6. Ascites
  7. Pleural effusions
68
Q

The severity of ovarian hyperstimulation syndrome is determined based on clinical features.
What are the clinical features for each subcategory:
Mild, moderate, severe, critical.

A

Mild: Abdominal pain and bloating

Moderate: Nausea and vomiting with ascites seen on ultrasound

Severe: Ascites, low urine output (oliguria), low serum albumin, high potassium and raised haematocrit (>45%)

Critical: Tense ascites, no urine output (anuria), thromboembolism and acute respiratory distress syndrome (ARDS)

69
Q

How is ovarian hyperstimulation syndrome managed?

A

Management is supportive with treatment of any complications.

  • Oral fluids
  • Monitoring of urine output
  • Low molecular weight heparin (to prevent thromboembolism)
  • Ascitic fluid removal (paracentesis) if required
  • IV colloids (e.g. human albumin solution)

YEAR 4- OBSTETRICS (6 decks)

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