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O&G: Gynaecology > Fertility and Subfertility > Flashcards

Fertility and Subfertility Flashcards

1
Q

When should investigations be offered to couples trying for a baby?

A

Only after 1 year of trying

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2
Q

What are the causes of subfertility?

A
  1. Ovulatory problems
  2. Male problems
  3. Tubal problems
  4. Coital problems
  5. Unexplained
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3
Q

What are the ovulatory causes of infertility?

A
  1. PCOS
  2. Hypothalamic hypogonadism - reduction in GnRH, reduced LH and FSH
  3. Kallmann’s syndrome - GnRH neurones fail to develop
  4. Pituitary causes - hyperprolactinaemia, pituitary damage (radiotherapy, Sheehan’s syndrome)
  5. Primary ovarian insufficiency - high FSH, low LH, can’t conceive with own eggs.
  6. Hypo/hyperthyroidism
  7. Androgen secreting tumours
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4
Q

What are the treatment options for subfertility in PCOS?

A
  1. Weight loss
  2. Clomiphene/metformin, then combine them
  3. Gonadotrophin induction of ovulation
  4. Ovarian diathermy
  5. IVF
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5
Q

What is the treatment of subfertility in hypothalamic hypogonadism and in what conditions is it common?

A
  1. Restoration of body weight

2. Anorexia nervosa, diets, athletes, high stress

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6
Q

What is the treatment for subfertility in Kallmann’s syndrome?

A

GnRH pump, if not wanting fertility then bone protection with COCP.

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7
Q

What is the treatment for subfertility in hyperprolactinaemia?

A

Cabergoline

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8
Q

What are the tubal/fertilisation causes of subfertility?

A
  1. PID (especially due to chlamydia)

2. Endometriosis

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9
Q

How do you test for tubal patency in subfertility?

A

Laparoscopy + dye test/HSG (+X-ray)/HyCoSy

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10
Q

What is the treatment of subfertility in PID?

A
  1. May respond to tubal catheterisation (increased ectopic risk)
  2. If adhesions present - adhesiolysis
  3. If conception does not occur - IVF
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11
Q

What is the treatment for subfertility in endometriosis?

A
  1. Laparoscopic surgery to remove endometriotic deposits

2. IVF next step if surgery fails

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12
Q

What is the process of analysing a semen sample in male subfertility?

A
  1. Last ejaculation occurring 2-7 days previously
  2. Sample must be analysed within 1-2 hours of production
  3. An abnormal analysis must be repeated 12 weeks later
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13
Q

What are the different types of male infertility?

A
  1. Low sperm count - oligozoospermia
  2. Low sperm motility - asthenozoospermia
  3. Abnormal sperm shape - teratozoospermia
  4. No sperm - azoospermia
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14
Q

What are the different causes of male infertility?

A
  1. Idiopathic oligospermia and asthenozoospermia (85%)
  2. Alcohol, smoking, steroids
  3. Varicocele
  4. Anti-sperm antibodies (vasectomy reversal)
  5. Mumps orchiditis, Klinefelter’s XXY, congenital absence of vas deferens, Kallmann’s, hyperprolactinaemia, retrograde ejaculation.
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15
Q

How is suspected male infertility investigated?

A
  1. ED? Undescended testes? Mumps as an adult?
  2. Examine for secondary sexual characteristics - testicular volume 15+ml, gynaecomastia.
  3. Test for - FSH, LH, testosterone, PRL, TSH
  4. Karyotype for 47XXY
  5. Men with azoospermia - examine for presence of vas deferens and test for CF
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16
Q

What is the conservative management of male subfertility?

A
  1. Smoking cessation, stop drinking and drugs, loose underwear and clothing.
  2. Start multivitamin - zinc, selenium, vitamin C
  3. Re-test sperm after 3 months
  4. If hypoG-hypoG - SC FSH/LH 3x per week for 6-12 months.
17
Q

What is the management of male subfertility if conservative management fails?

A
  1. Mild/moderate sperm dysfunction - intrauterine insemination
  2. Severe dysfunction - IVF/ICSI-IVF
  3. If azoospermic - sperm extracted from epididymis then ICSI-IVF
18
Q

What is important to ask in the history of subfertility?

A
  1. See both partners
  2. Previous pregnancy? Either partner have children?
  3. History of menstruation/STI/surgery
  4. Smoking and alcohol in both partners
  5. Frequency of sexual intercourse
19
Q

What baseline tests should be done in a presentation of subfertility?

A
  1. Chlamydia screening
  2. HbA1c
  3. Day 2-5 FSH
  4. TSH, PRL, testosterone, rubella status
  5. Mid-luteal progesterone
  6. Semen analysis
20
Q

What investigations are done in ovulatory causes of subfertility?

A
  1. Elevated mid-luteal progesterone indicates ovulation has taken place
  2. USS to serially monitor follicular size and growth
  3. OTC urine predictor kits indicate if LH surge has taken place
21
Q

What investigations are done in tubal and uterine causes of subfertility?

A
  1. Hysterosalpingogram uses X-ray and contrast through cervix
  2. HyCoSy (hysterosalpingo-contrast sonograph) similar but uses contrast and TVUSS
  3. TVUSS to rule out fibroids, polyps, and help confirm PCOS
22
Q

What are the indications for IVF?

A
  1. Tubal disease
  2. Male factor subfertility
  3. Endometriosis
  4. Last line ovulatory dysfunction
  5. Subfertility due to maternal age
  6. Unexplained subfertility >2 years
23
Q

What are the factors in the NHS funding criteria for IVF?

A
  1. Couples with no children
  2. Non-smokers
  3. BMI <30
  4. <42 years of age
24
Q

What are the two IVF protocols?

A
  1. Combination of FSH and LH or pure FSH as endogenous LH should be enough, give on 2nd day of cycle.
  2. GnRH analogue to suppress endogenous production, give back LH and FSH in controlled, easily manipulated amounts. Makes patients more sensitive to exogenous replacement. Daily injections, monitor by USS.
  3. Could also use GnRH pump
25
Q

Why does the LH surge need to be stopped in IVF?

A

To collect the ovaries with time, otherwise they will ovulate whenever. Artificial induction causes lots of follicles to make oestrogen, LH surge happens sooner.

26
Q

How is the LH surge stopped in IVF?

A

GnRH antagonist on day 6

27
Q

Why is hCG given 36 hours prior to egg collection in IVF?

A

To mature the eggs (doesn’t cause ovulation), as this would have been the job of the LH surge.

28
Q

How are the eggs collected in IVF?

A

Deep sedation (not GA), transvaginal probe guided by USS, withdraw fluid from follicles. Ensure eggs have polar body to confirm completion of meiosis I.

29
Q

How and why is progesterone prescribed after egg collection in IVF?

A
  1. On day of egg collection, vaginal pessary (2x per day) or IM injection.
  2. Maintains secretory environment in anticipation of embryo implantation (corpus luteum not functional).
30
Q

What is checked in the semen sample during IVF?

A
  1. Sperm count (>13million/ml)
  2. Sperm movement (32% making progressive movement)
  3. Sperm shape (>4% normal morphology)
31
Q

What is the process of IVF?

A
  1. Squirt 100,000 normal sperm around egg, wait 16-18 hours, 2 pro-nuclei should be present.
  2. If there are too few sperm or a spermatogenesis blockage, extract sperm from epididymis/testes and inject one sperm into an individual egg, intra-cytoplasmic sperm injection (ICSI).
32
Q

What is the process of embryo transfer in IVF?

A
  1. Put blastocyst back in to woman on day 5 of fertilisation.
  2. Only place 1-3 embryos dependent on age.
  3. Enter through cervix guided by USS and wait 11 days before confirming viability and implantation (pregnancy test).
33
Q

What is this describing?
Blastocysts stage, few cells taken from trophectoderm (becomes placenta) and using PCR, screen for genetic abnormalities.

A

Pre-implantation genetic diagnosis - embryos can be sexed for X-linked disease but not for social reasons.

34
Q

What are the complications of assisted conception?

A
  1. Ovarian hyperstimulation syndrome - caused by vasoactive products, haemoconcentration and hypercoagulability.
  2. Increased multiple pregnancies and ectopics
35
Q

What is this a presentation of?
Woman with abdominal discomfort, nausea and vomiting, distension, dyspnoea, 3-7 days after bhCG given for assisted conception.

A

Ovarian hyperstimulation syndrome

36
Q

What other avenues are there for assisted conception other than standard IVF?

A
  1. Oocyte donation
  2. Surrogacy
  3. ‘3-person baby’ for rare mitochondrial disease

O&G: Gynaecology (48 decks)

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