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Gynaecology > Fertility > Flashcards

Fertility Flashcards

1
Q

What are the causes of female anovulatory infertility? (3) and an example for each

A

3 main causes

Anovulatory infertility:
Ovarian dysfunction
-80% PCOS - normal gonadotrophins

Hypergonadotrophin hypogonadism
Absence of ovarian hormones
- primary ovarian failure
- resistant ovarian syndrome - FSH receptor abnormalities

Hypogonadotrophic hypogonadism
Failure of the pituitary to produce FSH, loss of GnRH secretion
- primary eg stress anorexia exercise
-surgery, irradiation, inflammation (sarcoidosis or TB) sheehans, congenital eg kallmans

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2
Q

What are the categories for causes for female infertility?

A

Ovarian function
Tubal
Uterine

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3
Q

What are the causes for tubal damage resulting in infertility?

A

Infection
usually chlamydia
Also appendicitis, septic miscarriage, TB and other intransigence pathology can damage the tube

Endometriosis
Inflammatory response

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4
Q

What are the causes of uterine infertility

A

Intrauterine adhesions
Ashermanns
Endometriosis

Submucosal Fibroid if by tubal Ostia

Congenital defects eg bicornuate doesn’t affect fertility but later pregnancy complications
No difference in rate with fertile and jnfertile woman

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5
Q

Causes of male factor infertility (6) and examples

No cause in 50%

A

Primary testicular dysfunction

  • failure of spermatogenesis eg trauma/ infection/ chemo
  • microdeletions of Y
  • chromosomal abnormalities eg kleinfelters

Obstructive

  • congenital absence of the vas def 10% ( if bilateral consider CF)
  • iatrogenic
  • infective

Endocrine

  • hypogonadotrophic hypogonadism
  • hypoprolactinaemia causes impotence not reduction in sperm count

Drugs

  • recreational eg EtOH marijuana and Tobacco affect function and production
  • chemo causes irreversible azooaspermia
  • ED for b blockers and antidepressants
  • reversible affect on spermatogenesis : steroids, sulfasalazine, antifungal

Environmental

  • occupational exposure to heat, radiation and chemicals
  • ?? Something we don’t know about

Varicocoele

New evidence that antisperm antibodies do not effect infertility and should not be tested for

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6
Q

what is an Varicocoele and how does it affect infertility

A

It is a dilatation of the pampiniform plexus (L>R due to insertion of the spermatic vein into the renal vein.)
Surgical correction should be for symptoms - it does not improve sperm count
11% in fertile men and 25% rate in infertile men
UTD recommends repair if grade three, large with abnormal semen analysis
poor evidence either way

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7
Q

What pre - conception testing / optimisation should be done before fertility treatment is started

A

• Cervical screening
• Antenatal screen - blood group, ABs FBC
• Viral screen - HIV, Hep B and C
• TSH
• Immunity screen: Rubella and varicella
offered rubella immunisation if non immune and avoid pregnancy for 1 month
• Screen for chlamydia before the uterus is instrumented (if positive, manage) - consider prophylactic antibiotics if not
• HbA1c if obese with PCOS
Weight loss, smoking cessation, manage EtOH

Folic acid for prevention of NTD 0.4mg daily. If prev NTD, on antiepileptic or diabetic then 5mg
- preconception up to 12 weeks

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8
Q

What is the clomiphine citrate challenge test

A

Clomiphine citrate challenge test - 100mg clomiphine day 5-9

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9
Q

Why when testing for ovarian reserve D3 FSH and estradiol

A

Measure D3 estradiol and FSH and D10 FSH
- lower reserve means higher FSH early in the cycle as the follicles of the ovary are not secreting enough hormone to suppress it

High D3 estradiol are due to advanced premature follicle recruitment that occurs in woman with poor ovarian reserve
Normal woman have enough hormone from small follciles in early cycle to suppress FSH - if this is high there are not enough early cycle follicles so FSH is high

high estradiol can falsely suppress FSH so if you just do FSH then you can be falsely reassured so must test both

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10
Q

Lifestyle advice for fertility

A

For men drinking 3-4 units / day is unlikely to affect their semen quality - Excessive alcohol is detrimental to semen quality
Smoking reduces fertility in M+W - + lifelong heath
No evidence with the relationship between caffeinated beverages and fertilty
High BMI (over 30) likely to take longer to conceive
If BMI over 30 and not ovulating weight loss will help
Group programmes with dietary and lifestyle advice are more successful then weight loss advice on its own
Men with BMI over 30 likely have reduced fertility
Woman with BMI under 19 and have irregular menstruation - it is likely that gaining weight will improve conception
Elevated scrotal temperature reduces semen quality but no evidence on wearing tight underwear
Screen for occupational exposure
OTC and recreational drug use can affect fertility
Complementary therapies are not evidenced based and not investigation is needed before the intervention can be recommended

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11
Q

Why does endometriosis cause infertility?

A

Local inflammatory state
endometriotic nodules secrete estradiol and progesterone that attracts macrophages, VEGF, IL 8 and cytokines
This is toxic to the gametes

Induced progesterone resistance

Impairing oocyte release
increased apoptosis of granulosa cells
Derranged follicular enviroment
Adhesions prevent oocyte release

Reducing sperm and embryo transport
Peritoneal macrophages phagocytose sperm
local inflammation impairs implantation

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12
Q

What is the rate of endo in fertile woman?

Infertile woman?

A

In woman with subfertility 50% have endometriosis

In fertile woman 5-10% have endo

In woman with endo 2-10% fecundity rate (compared with fertile couples 15-20%)

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13
Q

how does lipidol affect pregnancy rates ?

how long does that last for?

A

RCT showing tubal flushing with lipiodol increases pregnancy rates at 6 months, not at 2 years RR 4.4 48 vs 10%

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14
Q

What are the reasons to and not to resect endometriomas for infertility management

A

Exclude malignancy (1 extra ovarian cancer for every 10 000 woman with endometriosis – increased risk from 1/100 to 2/100)
Relieve symptoms
Reduce the risk of cyst complications (rare)
Facilitate transvaginal access to follciles

Risks
Reduced the number of oocytes able to be retrieved
Reduces peak oestradiol levels
Increased FSH requirement
In 13% of cases it leads to ovarian failure in that ovary
Surgical risk
May not benefit pregnancy rates

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15
Q

What are the indications for myomectomy in an infertile woman?

A

Indications for myomectomy in infertile woman

Fibroid size, number and location may impact on utility of myomectomy

Infertile woman / woman undergoing ART with submucosal fibroids

Infertile woman with symptomatic fibroids – HMB / pressure sx

Couples with multiple failed ART cycles with IM fibroids

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16
Q

what is the success rate of clomiphine ?

how does it work?

A

PCOS - 80% ovulation 30-40% pregnancy in 6/12

Bind to oestrogen receptors and have mixed agonist and antagonist activity

Primary site hypothalamus- blocking E receptors and negative feedback of E so increase in pulsatile GnRH and therefore FSH and LH. Likely also pituitary action.

In the ovary in a low E state it acts as an agonist enhancing FSH stimulation in the granulosa cell

Anti estrogen in the uterus cx and this may drop overall pregnancy rate - don’t get same build up of endometrium

17
Q

What are risks of clomiphine?

A

Twin 7-9% Triplet 0.3%
Hot flashes, breast discomfort, abdo pain and distension

OHSS rare

Visual symptoms like double or blurry vision – indication to stop treatment

Can cause luteal phase defect

18
Q

What lifestyle choices affect IVF success

A

Caffeine consumption has an adverse effect on outcome
BMI 19-29 - reduces success outside this
Smoking by either parent has a negative outcome of success
Alcohol more then 1 unit / day reduces the effectiveness of ART

19
Q

When is donor sperm indicated?

A

Donor insemination is used in situations where a male partner is infertile or in same-sex couples. However, the indications expanded such that it has become an alternative approach to fertility for some couples.
Donor insemination can also be considered in:

Couples in whom one or both partners are carriers of a heritable disease.
Couples who are serodiscordant for sexually transmissible viral infections.
Women without a male partner.
Couples who are incompatible for red cell antigens (e.g., D, Kell) associated with haemolytic disease of the newborn and with a history of a severely affected infant.

20
Q

What is the incidence of OHSS with IVF?

A

Mild ovarian hyperstimulation syndrome occurs in 33% of ART cycles, with severe OHSS occurring in 3.1–8.0% of cycles.

21
Q

What are the OHSS risk factors?

A

young age
polycystic ovarian disease
diabetes
previous OHSS
high follicular phase LH
high-dose gonadotrophin stimulation regimens
the use of GnRH analogues as opposed to GnRH antagonists
multiple follicular response with stimulation
high serum estradiol levels during treatment (>20 000 p/mol)
exposure to hCG, as trigger or luteal support
conception (increased in multiple pregnancy).

22
Q

How do reduce OHSS risk?

A

using low-dose stimulation protocols, or natural-cycle IVF
follicular monitoring
utilising GnRH antagonist cycles rather than GnRH analogues
utilising progesterone instead of hCG for luteal suppot
abandoning ART cycles prior to hCG administration and oocyte collection
delaying embryo transfer following collection and elective freezing of all embryos
coasting, whereby the hCG trigger is withheld until serum estradiol levels have returned to acceptable levels
GnRH agonist triggering the final maturation of oocytes, but pregnancy rates are reduced.

23
Q

What are early pregnancy complications in IVF?

A

0.7% ectopic
1/100 heterotopic

Spont loss 25%
twin loss 35% triplet 55%

24
Q

IVF AN risks ?

A

showed significantly increased rates of perinatal mortality, preterm delivery, low birth weight and neonatal intensive care unit admissions, placenta praevia, gestational diabetes and pre-eclampsia for IVF pregnancies.

25
Q

What is klinefelters?

A

47 XXY
Decreased libido, sparse facial hair, gynaecomastia and small firm testes
Assoc decrease T4, diabetes, asthma
No increased incidence of congenital malformations
Intellectual development in childhood may be mildly impaired
All are infertile
Testosterone replacement therapy should be commenced at adolescence and appears to have a beneficial effect both on psychosexual development and the long-term prevention of osteoporosis

26
Q

What is the rotterdam criteria

A

According to the Rotterdam consensus, 2 out of the 3 following criteria are required to confirm PCOS:

Oligo-ovulation or anovulation (usually demonstrated by oligo-amenorrhea or amenorrhea),
Clinical hyperandrogenism (hirsutism, acne) and/or biochemical hyperandrogenism (elevated serum androgen levels),
Unilateral or bilateral polycystic ovaries (PCO) on pelvic scan (≥12 antral follicles and/or ovarian volume of ≥10cm3),
after exclusion of less common hormonal pathology.

27
Q

What is meigs syndrome?

A

benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor. Ovarian fibromas constitute the majority of the benign tumors seen in Meigs syndrome.

28
Q

OHSS treatment

A

encourage oral fluids whenever possible
Crystalloid initially then consider if hct high albumin

intravenous diuretics to decrease the ascitic fluid and improve urine output is contraindicated

aspiration of the ovarian cysts is absolutely contraindicated

a 30–50 ml/hour is the minimal desirable urine output

NSAID for analgesia is contraindicated

heparin if admitted or OP if severe or critical

women presenting late are more likely to be pregnant and have a severe form of the syndrome, due to persistent hCG stimulation of the ovaries.

paracentesis if:
Uncontrolled pain
respiratory compromsie
Anuria despite colloid

29
Q

Should we use oil based dye for HSG?

A

May have a therapeutic effect - pregnancy rates higher in subfertile woman post procedure if oil based flush used

Oil based lye increases anaphylaxis and lipoid granulomas.
typically water based recommended

Gynaecology (27 decks)

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