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Fertility Flashcards

(54 cards)

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1
Q

Define infertility.

A

A disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.

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2
Q

Define primary infertility.

A

When a woman is unable to ever bear a child, either due to the inability to become pregnant or the inability to carry a pregnancy to a live birth she would be classified as having primary infertility.

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3
Q

Define secondary infertility.

A

When a woman is unable to bear a child, either due to the inability to become pregnant or the inability to carry a pregnancy to a live birth following either a previous pregnancy or a previous ability to carry a pregnancy to a live birth.

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4
Q

What are the causes of female infertility? (4)

A

Ovulatory Disorders
Tubal Damage
Uterine/peritoneal disorders
Unexplained infertility

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5
Q

How many % of cases of infertility have male factors?

How many have both female and male factors?

A

30%

40%

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6
Q

What are the three types of ovulatory disorders that cause infertility?

A

Type 1: Hypopituitary Failure (e.g. due to anorexia nervosa)

Type 2: Hypopituitary Dysfunction (eg PCOS, hyperprolactinaemia)

Type 3: Ovarian Failure (premature if under 40 yrs)

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7
Q

What are polycystic ovaries?

A

10 or more follicles per ovary on ultrasound

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8
Q

What are the diagnostic criteria for PCOS? (3)

A

Clinical hyperandrogenaemia
Oligomenorrhoea
Polycystic ovaries on ultrasound

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9
Q

What are the signs and symptoms of PCOS?

A 
Menstrual disturbance (oligomenorrhoea, amenorrhoea, DUB)
Infertility
Hirsutism
Acne
Male-pattern hair loss
Central obesity
Acanthosis nigricans
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10
Q

What can be seen on the blood test results in those with PCOS?

A 
Raised LH with normal FSH
Raised Testosterone (with or without reduced SHBG)
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11
Q

What are the differential diagnoses for PCOS that must be excluded? (4)

A

Thyroid dysfunction
Congenital adrenal hyperplasia
Hyperprolactinaemia
Androgen-secreting tumours

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12
Q

How does PCOS affect metabolism?

A

Abnormal serum lipid concentrations
Insulin resistance
Increased risk of developing diabetes mellitus

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13
Q

What are the tubal/uterine causes of infertility? (5)

A 
Pelvic Inflammatory Disease
Previous tubal Surgery
Endometriosis (tubal and uterine)
Fibroids (uterine)
Cervical mucus defect
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14
Q

Pelvic inflammatory disease - how many % develop tubal infertility after 1 episode? How many after 3 episodes?

A

More than 10%

50%

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15
Q

What are the symptoms of an acute PID episode? (5)

A 
Pelvic pain
Deep dyspareunia
Malaise
Fever
Purulent vaginal discharge
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16
Q

What causes chronic PID?

A

Inadequately treated acute PID

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17
Q

How is PID managed?

A

Rest
Abstinence
Antibiotics

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18
Q

What can be found on examination of PID?

A

Cervical excitation
Adnexal tenderness
Discharge
Pyrexia

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19
Q

What investigations are done for PID?

A

Smear - microscopy, culture and sensitivies plus chlamydia

FBC - raised ESR

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20
Q

What is endometriosis?

A

Presence of tissue histologically similar to endometrium outside the uterine cavity and myometrium (most commonly found in the pelvis).

Pain, dysmenorrhoea, menorrhagia, dyspareunia
Ex: pelvic tenderness or mass, fixed uterus.
Note laporoscopic findings common and don’t correlate to pain.

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21
Q

What are the risk factors for endometriosis? (3)

A

Increased risk with age, frequent cycles, family history

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22
Q

What protects against endometriosis? (2)

Study These Flashcards
A

Combined oral contraceptive pill

Pregnancy

23
Q

How is endometriosis managed?

Study These Flashcards
A

NSAIDs for pain
Norethisterone or COCP
Danazol and GnRH agonists
Surgery

24
Q

What are (uterine) fibroids?

Study These Flashcards
A

Uterine leiomyoma - benign tumours of the smooth muscle of the myometrium.

25
What do women with fibroids often complain of?
Heavy (regular) periods
26
How are fibroids treated?
Tran Acid Combined oral contraceptive pill/long acting reversible contraceptives Surgical resection
27
What are the male causes of infertility? (5)
Testicular (infection, cancer, surgical, congenital, undescended testes and trauma) Azoospermia (+/- sperm antibodies) Reversal of vasectomy Ejaculatory problems (retrograde and premature) Hypogonadism
28
What drugs are linked to infertility in women?
``` Long term NSAID use Chemotherapy Neuroleptics Spironolactone Depo-provera Marijuana, cocaine, and other illicit drugs ```
29
What drugs are linked to infertility in men?
Sulfasalazine Anabolic steroids Chemotherapy Chinese herbs for improving sperm count and motility Marijuana, cocaine, and other illicit drugs
30
If a couple has been trying to conceive for less than two years, they are not referred to a specialist. When might earlier referral be considered?
If the woman is aged 36 years or over | If there is a known clinical cause of infertility or a history of predisposing factors for infertility
31
What tests are done by the GP before a specialist referral?
``` Full Sexual/Contraception/Fertility History PCOS screen (day 21 progesterone, LH, FSH, serum testosterone, glucose) FBC Thyroid function tests/TSH Vitamin D HbA1c Viral screen (rubella, HIV, hepatitis) STI screen Check smear up to date Semen analysis ```
32
What three things does a semen analysis look for?
Volume (ml) - LRL 1.5ml Progressive Motility (%) - LRL 32% Morphology (%) - LRL 4% normal
33
What tests may be done in secondary care to investigate infertility?
Ovarian reserve testing (it tests how you would respond to gonadotrophin stimulation in IVF) HSG, HyCoSy (to assess tubal function) Laparoscopy (to assess uterine function)
34
How are type 1 ovulatory disorders managed?
Increase weight, decrease exercise. | Consider pulsatile GnRH or Gn with LH activity to induce ovulation.
35
How is PCOS-related infertility managed?
Weight loss to BMI of 30 or below Clomiphene or metformin - first line Combined clomiphene and metformin, laparoscopic ovarian drilling and Gn therapy - second-line
36
How is hyperprolactinaemia managed?
Bromocriptine
37
How are type 3 ovulatory disorders managed?
Consider donor eggs or alternataive parenting strategies
38
How is tubal/uterine infertility managed?
Laproscopic tubal surgery - catheterisaton/cannulation Surgery (fibroid/endometriosis clearance) Adhesiolysis Treatment of endometrosis
39
How is hypogonadism treated?
Gonadotrophins
40
What are the NHS guidelines for unexplained fertility management?
Do not offer clomiphene Advise to continue having regular unprotected intercourse for 2 years (investigations after 1 year) Offer IVF after 2 years
41
How is intrauterine insemination done?
Sperm is separated in lab and the slower speed sperm are removed before the partner is inseminated (via vaginal speculum and small catheter inserted into womb). Insemination takes place on day 12-16 in women who aren't on ovarian stimulating drugs. If they are on these drugs, vaginal ultrasounds are used to track the eggs - when the egg is mature, LH is injected to stimulate release and insemination is done 36-40 hours later.
42
Who is IUI offered to?
People unable to have vaginal intercourse Those requiring specific consideration (eg sperm wash in HIV positive men) Same-sex relationships
43
How many cycles of IUI are offered before IVF?
12 cycles
44
Who is IVF offered to?
Women under 40 who have not conceived after 2 years of unprotected intercourse or 12 cycles of artificial insemination (6 IUI) OR Women between 40-42 who have not conceived after 2 years, 12 cycles of AI, never previously had IVF, no evidence of low ovarian reserve)
45
How many cycles of IVF are offered to women?
3 full cycles | 1 cycle offered to 40-42 year old women
46
What are the stages of IVF?
1. Suppressing the natural monthly hormone cycle via daily injection or a nasal spray (for about two weeks). 2. Boosting the egg supply with gonadotrophins (daily injection for around 12 days). 3. Checking on progress through vaginal ultrasound scans and blood tests. Between 34 and 38 hours before eggs are due to be collected woman given a hormone injection to help eggs mature. 4. Collection of the eggs using ultrasound guidance while sedated. Collection of sperm sample-washed and prepared/frozen. 5. Eggs will be mixed with sperm and cultured in the laboratory for 16–20 hours after which they are checked for signs of fertilisation. Those that have been fertilised will be grown in the laboratory incubator for up to six days. The embryologist will monitor the development of the embryos and the best will then be chosen for transfer. Step 6. One or two embryos may be transferred if under 40, a maximum of three may be used if 40 years or over.
47
What are predictors of more successful outcome in IVF?
Age, less cycles, previous pregnancies, BMI 19-30, no smoking, no ectopic pregnancies, no caffeine.
48
What is intracytoplasmic sperm injection/how is it done?
Embryologist selects a single sperm to be injected directly into an egg.
49
When is ICSI indicated?
Severe deficits in semen quality Obstructive or non-obstructive azoospermia IVF has failed/resulted in poor fertilisation
50
What genetic issues should be considered with ICSI?
Karyotype for Kallman’s | Microdeletions on Y-chromosome
51
What is the benefit of ICSI compared to IVF?
Improves rate of fertilisation
52
What is a potential consequence of drugs used to stimulate ovarian function, such as gonadotrophin or clomifene?
Ovarian hyperstimulation syndrome
53
What are the signs and symptoms of mile and severe ovarian hyperstimulation syndrome?
Mild: Lower abdo discomfort/distention, with or without nausea. Severe: Abdo pain/distention, ascites, pleural effusion, venous thrombosis
54
What does IVF give a small increased risk of?
Borderline ovarian tumours

HD 2 (25 decks)

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