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Human Development 2 > Fertility > Flashcards

Fertility Flashcards

1
Q

What is the definition of subferitlity

A

Infertility

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2
Q

what is infertility

A

a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months (mark scheme also excepts 24 months) or more of regular unprotected sexual intercourse

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3
Q

what is 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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4
Q

What is 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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5
Q

what are the causes of infertility

A
  • Ovulatory disorders 25%
  • Tubal damage 20%
  • Uterine/peritoneal disorders 10%
  • Male factors 30%
  • Both male and female factors in 40% of cases where cause found
  • Unexplained inferitility 25%
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6
Q

how can women work out there ovulating

A

LH test = LH peaks 36 hours before ovulation

temperature = increase in basal temperature rate

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7
Q

what are the general conception advice

A
  • Intercourse throughout cycle
  • Smoking
  • Alcohol
  • Folic acid 400mg, unless other problems than 5mg
  • Weight
  • Stress
  • Caffeine – too much caffeine can cause stress levels to rise but no specific evidence
  • Drugs – don’t like lansoprazole during pregnancy which is a PPI
  • Occupation
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8
Q

what are the types of ovulatory causes of infertility

A

Type 1 - hypopituitary failure
type 2 - hypopituitary dysfunction
Type 3 - ovarian failure

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9
Q

describe examples of the different types of ovulatory causes of infertility

A
  • Type 1 – hypopituitary failure – can be caused by anorexia nervosa
  • Type 2 – hypopituitary dysfunction e.g. PCOS, hyperprolactinaemia
  • Type 3 – ovarian failure (premature ovarian failure if under 40 years)
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10
Q

what is the difference between the polycystic ovaries and the actual symptoms

A
  • need to have 2 out of 3 of the Rotterdam criteria to have PCOS
  • a 1/3 of all women have polycystic ovaries
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11
Q

what is the Rotterdam criteria for PCOS

A

 i)Clinical hyperandrogenaemia
 ii) oligomenorrhoea (less than 6-9 menses per year)
 Iii) 12 or more polycystic ovaries on ultrasound. Or ovaries greater than 10ml

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12
Q

what are the symptoms of PCOS

A
  • irregular periods or periods that don’t work
  • infertility hirsutism
  • acne
  • central obesity
  • acanthuses nigricans
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13
Q

describe the hormones of PCOS

A
  • Raised LH with normal FSH, Raised Testosterone (with or without reduced SHBG)
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14
Q

What does the raised testosterone in PCOS cause

A
  • acne

- infertility hirsutism

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15
Q

what are the differential diagnosis to PCOS

A
  • Exclude thyroid dysfunction, congenital adrenal hyperplasia, hyperprolactinaemia, androgen-secreting tumours.
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16
Q

what are people with PCOS at increased risk of

A
  • If PCOS is confirmed they are at increased risk of altered lipid metabolism, and outside of pregnancy is to reduce weight is the best advice that can be given
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17
Q

List some tubal and uterine causes of infertility

A
  • Pelvic inflammatory disease
  • Previous tubular surgery including tubal surgery for ectopic pregnancy
  • Endometriosis (tubal and uterine)
  • Fibroids (uterine)
  • Cervical mucus defect – some peoples cervical mucus is the wrong pH and this can kill the sperm
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18
Q

describe PID symptoms

A
  • Asymptomatic
  • pelvic pain
  • deep dyspareunia
  • malaise
  • fever
  • purulent vaginal discharge
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19
Q

describe the percentage cause of infertility and the increase in PID

A

 More than 10% develop tubal infertility after 1 episode, 50% after 3 episodes

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20
Q

How do you treat PID

A
  • antibiotics
  • rest
  • abstinence
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21
Q

what is the dentition of endometriosis

A

 Presence of tissue histologically similar to endometrium outside the uterine cavity and myometrium
 Most commonly found in the pelvis.

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22
Q

what are the symptoms of endometriosis

A

 Pain, dysmenorrhoea, menorrhagia, dyspareunia

 Ex: pelvic tenderness or mass, fixed uterus

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23
Q

describe the aetiology of endometriosis

A
  • 1 in 5 women affected
  • increased risk with age
  • FH
  • frequent cycles
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24
Q

How can you treat endometriosis

A

 NSAIDs for pain, Norethisterone or COCP (4 packets run together),
 Secondary Care-Danazol and GnRH agonists, Surgery.

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25
Q

What is another word for fibroids

A

uterine leiomyoma

- Benign tumours of the smooth muscle of the myometrium

26
Q

who is fibroids common in

A

 Approx 20% women (inc common in Afro-Carribean women)

27
Q

what do people with fibroids complain of

A

 Complain of heavy, regular periods

28
Q

How do you treat fibroids

A

 Tranexamic Acid, COCP/LARCs

 Surgery

29
Q

what is a difference between POCS and fibroids

A

PCOS is irregular periods where as fibroids is regular heavy periods

30
Q

name and describe male causes of inferiority

A

 Testicular (infection, cancer, surgical, congenital, undescended testes and trauma).
 Azoospermia with or without sperm antibodies
 Reversal of vasectomy – less common as LARCs used more frequently with women
 Ejaculatory problems (retrograde and premature)
 Hypogonadism
 (Although not male infertility directly think about Erectile Dysfunction disorders: diabetes, depression and other psychological causes, stress is the most common cause and then we think about diabetes as well)

31
Q

What are drugs for women that are linked to infertility

A
  • Women long term NSAID use, chemotherapy, neuroleptics, spironolactone, depr-provera
  • Marijuana, cocaine, other illicit drugs for both male and female
32
Q

What are drugs for men linked to infertility

A
  • Men- sulfasalazine, anabolic steroids, chemotherapy, chiense herbs for improving sperm count and motility
  • Marijuana, cocaine, other illicit drugs for both male and female
33
Q

describe the number of people who get pregnancy in the first year and then in the second year

A

 80% couples pregnant after 12 cycles and 50% of the remainder conceive in the second year.

34
Q

what are the NICE guidelines for referring someone with subfertility

A

“Offer an earlier referral for specialist consultation to discuss options for attempting conception, further assessment and appropriate treatment if:

  1. The woman in aged 36 years or over, and
  2. There is a known clinical cause of infertility or a history of predisposing factors for infertility
35
Q

what do you screen both males and females for in primary care

A

 Full Sexual/Contraception/Fertility History.
 PCOS screen- day 21 progesterone, LH, FSH, serum testosterone, glucose
 FBC (fibroids)
 TFTs/TSH
 Vitamin D
 HbA1c (if any abnormality on glucose on PCOS screen)
 Viral screen-Rubella, HIV, Hepatitis Screen

36
Q

what does a semen analysis look for

A

 WHO Ranges for Sperm Count:
• Volume (ml) Lower Range Limit 1.5ml
• Progressive Motility (%) Lower Range Limit 32%
• Morphology (%) Lower Range Limit 4% normal

37
Q 
how do you assess 
- ovarian function 
- tubal function 
- uterine function 
in secondary care
A

 To assess ovulatory function:
• Bloods not done in primary care;
• Ovarian reserve testing-how female would respond to Gonadotrophin stimulation in IVF;

 To assess tubal function: Hysterosalpingogram – this is when dye is injected in the room to look at the patency of the fallopian tubes – this can be painful

 To assess uterine function: laparoscopy – for endometrioses to understand how significant things are

38
Q

How do you treat type 1 hypopituitary failure as a cause of ovulatory infertility

A
  • increase weight, decrease exercise.

* Consider pulsatile GnRH or Gn with LH activity to induce ovulation

39
Q

How do you treat someone with PCOS who wants to get pregnancy

A
  • Clomiphene
  • weight loss of patient is overweight
    surgery
  • ovary drilling
    wedge resection
40
Q

How do you treat someone with PCOS who does not want to get pregnant

A
  • low dose contraceptive pills in order to restore menstrual regulatory
  • metformin
  • anti-androgens (e.g,cyproterone acetate)
41
Q

how do you treat hyperprolactinaemia

A

Bromocriptine which is a dopamine agonist

42
Q

how do you treat ovarian failure

A

consider donor eggs through assisted fertility, alternative parenting strategies.

HRT – protect bones and protect cardiovascular system, kept on HRT until reach menopause age of 51

43
Q

what is the management of tubular problems causing infertility

A

 Laproscopic tubal surgery-catheterisation/ cannulation
 Surgery Prior to IVF attempt-fibroid/endometriosis clearance.
 Adhesiolysis
 Treatment of Endometriosis

44
Q

what are the NICE guides for unexplained infertility

A

Do not offer clomiphene-no increased chance of pregnancy or live birth (NOTE INTERNET PURCHASES - watch out that they don’t do these).

To continue having regular unprotected intercourse for 2 years (investigations after 1 year).
Offer IVF after 2 years.

45
Q

what happens in intrauterine insemination IUI

A

 Sperm is separated in lab, removal of slower speed sperm, before partner is inseminated (partner or donor).

46
Q

Who do you offer intrauterine insemination IUI to

A
  • People who are unable to have vaginal intercourse (disability).
  • Requiring specific consideration (eg sperm wash in HIV pos men)
  • Same-sex relationships
47
Q

How many cycles do you have of IUI before you offer IVF

A

 12 cycles in total before offer IVF

48
Q

what happens in IVF

A

 Fertilisation of an egg (or eggs) outside the body then inseminated.
 The treatment can be performed using own eggs and sperm, or using either donated sperm or donated eggs, or both.

49
Q

who should you offer IVF to

A
  • Offer 3 cycles to Women under 40 who have not conceived after 2 years of unprotected intercourse or 12 cycles of artificial insemination (6 IUI).
  • Offer one cycle to 40-42 year old women if 2 years unprotected intercourse,12 cycles AI (6 or more IUI), never previously had IVF & no evidence of low ovarian reserve.
50
Q

what are the predictors of successful outcome of IVF

A

 Predictors of more successful outcome in IVF are Age, less cycles, previous pregnancies, BMI 19-30, no smoking, no ETOH, no caffeine.

51
Q

what is ovarian hyperstimulation syndrome

A

 Consequence of drugs used to stimulate ovarian function in IVF or PCOS

52
Q

what are the symptoms of ovarian hyper stimulation syndrome

A

 Mild: Lower abdo discomfort/distention, with or without nausea.
 Severe: Abdo pain/distention, ascites, pleural effusion, venous thrombosis

53
Q

how does intracytoplasmic sperm injection work (ICSI)

A

 Embryologist selects a single sperm to be injected directly into an egg, instead of fertilisation taking place in a dish where many sperm are placed near an egg.

54
Q

when do you offer intracytoplasmic sperm injection (ICSI)

A
  • Severe deficits in semen quality
  • Obstructive azoospermia
  • Non-obstructive azoospermia
  • Couple in whom previous IVF treatment cycle has resulted in failed or very poor fertilisation
  • Appropriate investigations (eg semen analysis) for dx.
  • Consider genetic issues (karyotype for Kallman’s) and microdeletions on Y-chromosome.
55
Q

ICSI improves fertilisation rates …

A

• ICSI improves fertilisation rates compared to IVF alone, but once fertilisation taken place, the pregnancy rate is no better than with IVF

56
Q

what are the safety risks with IVF

A

• Small increased risk of borderline ovarian tumours +/- ICSI

57
Q

what do you do for people who wish to persevre fertility with cancer

A

 Use sperm, embryos or ooctyes in cryopreservation.

 Offer sperm cryopreservation in adolescent boys and men undergoing Ca treatment thought to render them infertile.
 Offer oocyte/embryo cryopreservation to women of reproductive age if well enough to undergo ovarian stimulation and egg collection and enough time available before cancer Rx starts.

58
Q

What are the 3 stages of the ovarian cycle

A

Follicular phase - day 1-10
Ovulatory phase - day 11-14
Luteal phase: day 15 - 28

59
Q

describe the 3 stages of the ovarian cycle

A

Follicular phase: days 1 to 10
 5-12 primordial follicles stimulated each month: one grows and matures.
 GnRH secreted from hypothalamus: stimulates anterior pituitary to secrete LH and FSH.
o These stimulates follicle to grow.
 Mature follicle secretes oestrogen.
o Inhibits further LH and FSH secretion by
anterior pituitary (negative feedback).
o Stimulates growth of endometrium.

Ovulatory phase: days 11 to 14
 Negative feedback is temporary: oestrogen
stimulates HPA resulting in burst of LH and FSH.
o Completion of meiosis I, onset of meiosis II
in the oocyte.

Luteal phase: days 15 to 28
 Granulosa cells of mature follicle divide and form
the corpus luteum
 Secretes progesterone and oestrogen. Prepares uterine endometrium for implantation

60
Q

what are the 3 stages of the menstrual cycle

A

Menstrual phase = day 1-5
Proliferative phase = day 6-14
Secretory phase = day 15-28

61
Q

describe the 3 stages of the menstrual cycle

A 
Menstrual phase (day 1-5):
 Due to withdrawal of steroid support (oestrogen/progesterone) the endometrium collapses.
 Endometrium is shed with blood from ruptured arteries (blood loss: 50-150ml).

Proliferative phase (day 6-14):
 Oestrogen from mature follicle stimulates thickening of
the endometrium.
 Glands/spinal arteries form.
 Oestrogen also causes the growth of progesterone
receptors on endometrial cells.

Secretory phase (day 15-28):
 Progesterone from corpus luteum: acts on endometrium.
Enlargement of glands  secret mucus and glycogen in
preparation for implantation of fertilised oocyte.
 No fertilisation = corpus luteum degenerates  corpus
albicans. Progesterone levels fall.

Human Development 2 (34 decks)

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