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Year 4 GOSH > Fertility > Flashcards

Fertility Flashcards

1
Q

How common is subfertility?

A

Very common - 1 in 6 couples seek specialist help

Approx 82% will achieve pregnancy in 1 year of regular unprotected sexual intercourse (UPSI)

92% after 2 years

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2
Q

What are some causes of subfertility? (6)

A

1) Ovulation disorder - 21%
2) Tubal factors - 15-20%
3) Male factors - 25%
4) Unexplained - 28%
5) Endometriosis - 6-8%
6) Sexual dysfunction - 4-5%

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3
Q

What are some causes of primary anovulation? (4)

A

Primary ovarian failure:

1) Premature ovarian syndrome
2) Genetic eg Turner’s syndrome 45 XO, primary hypogonadism
3) Autoimmune
4) Iatrogenic eg surgery, chemo

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4
Q

What are some causes of secondary anovulation? (6)

A

Secondary ovarian failure:

1) PCOS
2) Excessive weight loss or exercise
3) Hypopituitarism eg tumour, trauma or surgery
- Panhypopituitarism = Simmonds’ disease
4) Sheehan’s disease - pituitary infarction following PPH shock
5) Kallman’s syndrome: anosmia, hypogonadotrophic hypogonadism
6) Hyperprolactinaemia

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5
Q

What is premature ovarian syndrome?

A

aka primary ovarian insufficiency

Loss of normal function of your ovaries before the age of 40

Occurs in approx 1% women

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6
Q

What is primary hypogonadism? What would hormone levels be?

A

= Primary ovarian insufficiency/hypergonadotrophic hypogonadism
Condition of the ovaries or testes

Decreased testosterone / oestrogen
Raised LH (+/- FSH)
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7
Q

What is secondary hypogonadism? What would levels of testosterone and LH be?

A

= Hypogonadotrophic hypogonadism

Condition of the hypothalamus or pituitary

Decreased LH (+/-FSH)
Decreased testosterone / oestrogen
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8
Q

What is the WHO classification of disorders of ovulation?

A

Group I: hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism

Group II: hypothalamic-pituitary-ovarian dysfunction. Predominantly PCOS. This is the vast majority of ovulation disorder

Group III: Ovarian failure

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9
Q

What is the most common cause of anovulatory subfertility?

A

PCOS

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10
Q

What factors may affect the tubes, uterus of cervix? (6)

A

1) Infection:
- PID
- Following termination or miscarriage from retained products of conception
- STI
- Infection spread eg appendicitis
- Adhesions in uterus and cervix following infection = Asherman’s syndrome

2) Deformity eg septum or bicornuate uterus
3) Significant distortion of uterine cavity eg by fibroids
4) Shortened or damaged cervix from cone biopsy
5) Problems of cervical mucus eg inhospitable to sperm
6) Endometriosis

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11
Q

What are important features for a fertility history? (15)

A
  • Age
  • Duration of subfertility
  • Coital frequency
  • Menstrual cycle regulatory and LMP (?pregnant)
  • Pelvic pain eg dysmenorrhoea, dyspareunia
  • Cervical smear hx
  • Previous pregnancies
  • Hx ectopic
  • Hx tubal/pelvic surgery
  • Prev/current STI
  • Prev PID
  • Drug hx
  • Smoking
  • Alcohol
  • Folic acid
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12
Q

What should be checked in an examination when investigating subfertility? (General and pelvic)

A 
General
- BMI
- Signs of endocrine disorder: 
Hyperandrogenism (acne, hair growth, alopecia)
Acanthosis nigricans
Thyroid disease
Visual field defects (?prolactinoma)

Pelvic

  • Exclude obvious pelvic pathology eg adrenal masses, uterine fibroid, endometriosis (painful fixed uterus)
  • Cervical smear
  • Chlamydia screening
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13
Q

What investigations should be done in primary care for subfertility?

A

Chlamydia screening
Baseline (day 2-5) hormone profile:
- LH and FSH = high levels suggest poor ovarian function, and a comparitively high LH level relative to FSH can occur in PCOS
- TFH
- Prolactin
- Testosterone
Rubella status
Mid-luteal progesterone level (to confirm progesterone = >30nmol/L)
Semen analysis - this should be done first as 30% of subfertility from males and this is an easy OPD procedure

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14
Q

What investigations are done in secondary care for female subfertility?

A

Assessment of tubal patency

Ovarian reserve testing

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15
Q

How is tubal patency assessed? (2)

A

1) Hysterosalpingogram (HSG) / hysterosalpingo-contrast US

2) Laparoscopy and dye test

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16
Q

What are some pros and cons of hysterosalpingogram / hysterosalpingo-contrast US?

A

For women who are not known to have co-morbidities (eg PID, ectopic pregnancy or endometriosis)

Pros:

  • Good sensitivity and specificity
  • Easily done
  • Takes less than 5 mins

Cons:

  • Can be uncomfortable
  • Requires x-ray
  • May have false positive results (eg suggesting tubal blockage due to spasm)
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17
Q

What are some pros and cons of laparoscopy and dye test?

A

= Gold standard: day case procedure which can combine with a hysteroscopy to assess the uterine cavity is necessary

For women with comorbidities

Pros:
- Pelvic pathology (eg endometriosis or peritubular adhesions) can be diagnosed and treated

Cons:

  • Requires GA
  • Carries surgical risk
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18
Q

What 3 features can be measured to test ovarian reserve and thus to predict a likely ovarian response to gonadotrophin stimulation in IVF?

A

One of the following should be measured (approx day 3 of menstrual cycle) to predict likely ovarian response to gonadotrophin stimulation in IVF:

1) Total antral follicle count
2) Anti-Mullerian hormone
3) FSH

A higher response results in more mature follicles developing, leading to high-than-average pregnancy rates

NB: age should be used as an initial predictor of overall chance of success

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19
Q

What is the management of female subfertility?

A

Referral for specialist care should be considered after 1 year of trying, although further investigations may be required if:

  • Female >35yr
  • Known fertility problems
  • Anovulatory cycles
  • Severe endometriosis
  • Prev PID
  • Malignancy
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20
Q

What are some methods for ovulation induction?

A

1) Correction of specific problem eg hyperprolactinaemia or weight loss
2) Anti-oestrogens
3) Gonadotrophins or pulsatile GnRH
4) Laparoscopic ovarian diathermy
5) Insulin sensitizers eg metformin
6) Surgery

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21
Q

What lifestyle modification should be advised to help subfertility?

A

Healthy diet
Smoking cessation / recreational drugs
Reduce alchohol consumption
Regular exercise
Folic acid
Avoid timed intercourse - have every 2/3 days
Avoid ovulation induction kits / basal temp measurements - no evidence it works and stressful

22
Q

What is an example of an anti-oestrogen? How does it work?

A

Clomifene 50mg days 2-6

Increases endogenous FSH via negative feedback to the pituitary

23
Q

What are some side effects of anti-oestrogens?

A

Hot flushes, mood liability

Limited to 12 cycle maximum due to possible link with ovarian cancer

Causes multiple pregnancies 5-8% of the time

Need USS monitoring as cycle can be abandoned if over response

24
Q

What pharmacological treatment is used 2nd line after anti-oestrogens?

Who are they used for?

A

Gonadotrophins or pulsatile GnRH

Used for low oestrogen/normal FSH of for clomifene resistant PCOS

Given as injections

25
Q

What does laparoscopic ovarian diathermy aim to do? How long does it last?

A

Aims to restore ovulation in women with PCOS

Effects last 12-18 months if successful

26
Q

When are insulin sensitisers eg metformin used to induce ovulation?

A

Often used in women with PCOS however not licensed for this

May achieve spontaneous ovulation

Can be combined with clomifene to increase efficacy

Weight loss is more effective

27
Q

What surgery is offered to induce ovulation?

A

Treat endometriosis - laser / diathermy / excision

Tubal surgery - microsurgery / adhesiolysis

28
Q

What are some causes of male subfertility? (4)

A

1) Semen abnormality (85%)
2) Azoospermia (5%)
3) Immunological (5%)
4) Coital dysfunction (5%)

29
Q

What are some causes of semen abnormality?

A

1) Idiopathic oligoasthenoteratozoospermia (OATS)
2) Testis cancer
3) Drugs eg alcohol / nicotine
4) Genetic
5) Varicocele

30
Q

What is idiopathic oligoasthenoteratozoospermia (OATS)?

A

Approx 30% of male infertility cases

All 3 of:

1) Oligozoospermia = low number of sperm
2) Asthenozoospermia = poor sperm movement
3) Teratozoospermia = abnormal sperm shape

31
Q

What are some causes of azoospermia? (12)

A

= Semen contents no sperm

1) Pretesticular
- Anabolic steroid use
- Idiopathic hypogonadotrophic hypogonadism (HH)
- Kalmann’s
- Pituitary adenoma

2) Non-obstructive
- Cryptochordism
- Orchitis
- 47XXY
- Chemo-radiotherapy

3) Obstructive
- Congenital bilateral absence of the vas deferens (CBAVD)
- Vasectomy
- Chlamydia
- Gonorrhoea

32
Q

What are some immunological causes of male subfertility? (4)

A

1) Antisperm antibodies
2) Idiopathic
3) Infection
4) Unilateral testicular obstruction

33
Q

What are some causes of coital dysfunction?

A

1) Mechanical cause with normal sperm function
2) Abnormal ejaculation
- Hypospadias
- Phimosis
- Disability
3) Retrograde ejaculation (sperm enters bladder instead of emerging through penis)
- DM
- Bladder neck surgery
- Phenothiazines
4) Failure in ejaculation:
- MS
- Spinal cord / pelvic injury

34
Q

What is hypospadias?

A

Congenital condition in which the opening of the urethra is on the underside of the penis instead of the tip

35
Q

What is phimosis?

A

Condition in which the foreskin is too tight to be pulled back over the glans penis

36
Q

When should investigations start for male subfertility?

A

Investigations should start in primary care after 1 year of unsuccessful trying

Earlier if hx genital surgery, cancer treatment of previous subfertility

37
Q

What investigations should be performed for male subfertility?

A

1) Semen analysis
2) FSH - increased in testicular failure
3) Karyotype - exclude 47XXY
4) CF screen - CBAVD

38
Q

What 3 features are measured in a semen analysis and what are the normal ranges?

A

1) Volume = >2ml
2) Concentration = >20 x 10^6/ml
3) Motility = >50ml

Azoospermia = no sperm in ejaculate
Oligospermia = reduced number of sperm in ejaculate
39
Q

What is the management of male subfertility? (9)

A

1) Treat any underlying medical conditions
2) Address lifestyle issues eg reduce alcohol, stop smoking
3) Review medications
4) Medical treatments
5) Surgical
6) Sperm retrieval
7) Assisted reproduction
8) Sperm donor
9) Adoption

40
Q

What medications may need to be reviewed in male subfertility?

A

Antispermatogenic:

  • Alcohol
  • Anabolic steroids
  • Sulfasalazine

Antiandrogenic (testosterone blockers)

  • Cimetidine
  • Spironolactone

Erectile / ejaculatory dysfunction:

  • Alpha or beta blockers
  • Antidepressants
  • Diuretics
  • Metoclopramide
41
Q

What are some medical treatments for male subfertility?

A

Gonadotrophins in hypogonadotrophic hypogonadism

Sympathomimetics (eg imipramine) in retrograde ejaculation

42
Q

What are some surgical treatments for male subfertilty?

A

Relieve obstruction
Vasectomy reversal

NB surgical treatment of varicocele does not improve pregnancy rate and thus is not indicated

43
Q

What is sperm retrieval?

A

Either from postorgasmic urine in retrograde ejaculation or surgical sperm retrieval from testis (greater chance of success if FSH is normal)

This is then used in assisted reproduction:

IUI = Intrauterine insemination or ICSI = intracytoplasmic sperm injection (single sperm injected directly into an egg)

44
Q

What are the five main methods of assisted reproduction?

A

1) IVF
2) Intra-cytoplasmic sperm injection = ICSI
3) Pre-implantation genetic diagnosis = PGD
4) Egg donation
5) Surrogacy

45
Q

What are some indications for IVF? (5)

A

1) Tubal disease
2) Male factor subferility
3) Endometriosis
4) Anovulation
5) Decerased fecundity with increased maternal age

46
Q

What factors affect the success of IVF? (6)

A

1) Duration of subfertility
- Less success with increased duration
2) Age
- Pregnancy rates highest ages 25-35yr with a steep decline there after
3) Basal FSH level
- Elevated basal FSH indicates rescued ovarian reserve (and also poor oocyte quality)
4) Previous pregnancy
- Higher chance of successful IVF outcome
5) Previous failure IVF cycles
- Decreases success
6) Smoking and high BMI
- Decreases success

47
Q

How is IVF carried out?

A

1) Ovaries stimulated with FSH and encouraged to produce up to 8-10 follicles
2) Induction of ovulation with an injection of hCG
3) Eggs collected during an US guided procedure with fine needle
4) These eggs fertilised in a petri dish / sperm injected daily into the egg (intracytoplasmic sperm injection, ICSI0
5) When fertilisation occurs, the fertilised embryo(s) is then replaced into the uterine cavity
6) Approx 2 weeks after embryo transfer, a pregnancy test is performed to check for successful implantation

48
Q

What are some risks of IVF? (3)

A

1) Inc risk ectopic (3-4% higher)
2) Inc risk ovarian hyper-stimulation syndrome
3) Small risk of infection and haemorrhage during embryo transfer

49
Q

What are some benefits of IVF?

A

Reduced risk of prematurity, stillbirth and miscarriage

50
Q

What is the success rate of IVF per cycle in women <35yr?

A

30%

51
Q

What is ovarian hyperstimulation syndrome (OHSS)?

A

Vasoactive products released from the ovaries increase capillary permability

Leads to fluid accumulation in the interstitial space and dehydration

52
Q

How may a woman with ovarian hyperstimulation syndrome (OHSS) present?

A

1) Ascites
2) Hugely enlarged multifollicular ovaries
3) Pulmonary oedema
4) Risk of multiorgan failure and coagulopathy

Year 4 GOSH (16 decks)

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