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Becks Gynaecology Qs > Fertility and subfertility > Flashcards

Fertility and subfertility Flashcards

1
Q

What is the definition of subfertility?

A

When a couple has been having regular unprotected intercourse for a year with no conception.

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2
Q

What are the 4 basic conditions required for pregnancy?

A
  1. Ovulation of an egg (30% of cases have anovulatory cycles)
  2. Viable sperm (25% cases have a problem)
  3. Sperm reaching the egg (damage to fallopian tube in 25% of cases)
  4. Fertilised egg implanting in the uterus endometrium
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3
Q

What are the most common contributors to subfertility?

A 
Ovulatory problems (30%)
Male problems (25%)
Tubal problems (25%)
Coital problems (5%)
Cervical problems (<5%)
Unexplained (30% - most likely to do with implantation)

More than one cause might be present which is why the total is more than 100%.

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4
Q

What is the physiological process of ovulation?

A

Anti-mullerian hormone (AMH) is produced from small (not large) ovarian follicles and reduces the release of oestrogen.
At the beginning of each cycle, low oestrogen levels exert a positive feedback to cause hypothalamic GnRH pulses to stimulate the pituitary gland to produce FSH and LH.
As the follicle grows, production of AMH reduces and oestrogen increases.
Intermediate oestrogen levels cause negative feedback on FSH and LH so less is produced.
The maturing follicles are competing for the LH and FSH and only one is large enough (dominant follicle) to survive and continue to grow.
When high oestradiol is attained, the negative feedback is reverse and positive feedback causes FSH and LH to rise dramatically - it is the LH peak that causes the now ripe follicle to rupture.
This is ovulation.

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5
Q

What happens if embryo implantation occurs?

A

Rather than the corpus luteum involuting at the end of the cycle, the hCG produced by the trophoblast tissue acts on the corpus luteum to maintain oestrogen and progesterone production until the fetoplacental unit takes over at 8-10 weeks.

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6
Q

What investigations are used to detect ovulation?

A

Progesterone levels in the mid-luteal phase (day 21 of a 28 day cycle it peaks - basically 7 days before menstruation).
OTT urine predictor kits will indicate if the LH surge has taken place.
Temperature charts and US monitoring of follicles are methods but not used.

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7
Q

What is polycystic ovary?

A

This describes a characteristic transvaginal US appearance of multiple (12 or more) small follicles in an enlarged ovary.
There are no symptoms of the syndrome.

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8
Q

What is polycystic ovarian syndrome?

A

When 2 of the 3 criteria are met:

  1. PCO on ultrasound
  2. irregular periods (>35 days apart)
  3. Hirsutism (clinical - acne/excess body hair - or biochemical - raised testosterone)
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9
Q

What is the pathology of PCOS?

A

They have disordered LH production and insulin resistance and hence have higher circulating insulin levels.
Insulin and LH levels cause increased ovarian androgen production and insulin causes increased adrenal androgen production.
Increased ovarian androgens disrupt folliculogenesis, leading to excess small follicles and irregular/absent ovulation.
Raised peripheral androgens causes hirsutism.

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10
Q

What is the link between excess body weight and PCOS?

A
  1. Obesity can cause PCO to become PCOS
  2. Obesity increases insulin resistance and therefore increases peripheral androgen production from the adrenals –> hirsutism.
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11
Q

What hormones should be measured to exclude other diagnoses?

A

FSH
AMH
prolactin
TSH

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12
Q

What are the affects of ovarian failure, hypothalamic failure and PCOS on FSH?

A

Ovarian failure = FSH raised
Hypothalamic = FSH low
PCOS = FSH normal

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13
Q

What is the affect of PCOS on AMH levels?

A

Raised

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14
Q

What are the problems with PCOS and pregnancy?

A

Subfertility

Miscarriage

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15
Q

What are the complications of PCOS?

A 
50% develop type 2 diabetes
30% develop gestational diabetes
Endometrial cancer (due to unopposed oestrogen action)
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16
Q

What are the treatments for PCOS (not including fertility)

A

Weight loss - diet and exercise.

COCP to regulate menstruation and treat hirsutism - need at least 3 or 4 bleeds a year to protect endometrium.

Antiandrogens (spironolactone or cyproterone acetate) to treat hirsutism but conception should be avoided. Eflornithine is a topical antiandrogen used for facial hirsutism.

Metformin - sensitises to insulin and therefore reduces insulin levels and consequent androgen levels.

17
Q

What are the causes of anovulation, other than PCOS?

A

Hypothalamic hypogonadism - anorexia, Kallmann’s syndrome (GnRH neurones don’t develop and they need GnRH pump to induce ovulation or HRT to protect bones).

Hyperprolactinaemia - excess prolactin production from the pituitary reduces GnRH release. Associated with PCOS, anti-psychotics, tumours, hypothyroidism.

Pituitary damage e.g. Sheegan’s syndrome after birth - production of GnRH is normal but FSH and LH are reduced.

Premature ovarian insufficiency

Gonadal dysgenesis

The luteinised unruptured follicle syndrome

Androgen producing tumour

Hypo- or hyperthyroidism

18
Q

What is the treatment for hyperprolactinaemia?

A

Dopamine agonist (bromocriptine or cabergoline) because dopamine usually inhibits prolactin release.

19
Q

What is premature ovarian insufficiency?

A

Failure of the ovaries results in no oestradiol and inhibin to inhibit FSH and LH, so theres are high.
AMH is low because there are so few small follicles in the ovary and US shows a low antral follicle count.
Need a donor egg for conception and pregnancy.
Bone protection and HRT is required for bone health.

20
Q

What are the first and second line treatments for PCOS induction of ovulation? What happens if these fail?

A

First line:
Clomifene
Metformin

Second line:
Clomifene + metformin
Gonadotrophins
Ovarian diathermy

Fail? = IVF.

21
Q

What does clomifene do?

A

It results in ovulation and live births in 70% and 40% respectively.
It is an anti-oestrogen, blocking oestrogen receptors in the hypothalamus and pituitary. This makes the pituitary think that there is no oestrogen and therefore produces more FSH and LH.
It is given days 2-6 and then the cycle is self-perpetuating.
Ovarian follicles are monitored - if no follicles develop then more is given the next time, and if 3 or more develop then less is given next time and the cycle is cancelled.

22
Q

What is the hypothesised reason for clomifene’s ovulation rate being 70% but live birth being 40%?

A

Due to it’s action on the endometrium - it causes thinning.

23
Q

For which women is clomifene better than metformin?

A

In those with BMI < 30, metformin is more efficacious. In those with a BMI > 30, clomifene works better.

24
Q

Explain gonadotrophin induction of ovulation

A

Recombinant or purified urinary LH and FSH acts as a substitute for normal pituitary production.
Given as daily subcutaneous injections (small increases incrementally in PCOS to prevent multiple follicles).
Recombinant LH or hCG (similar to LH) is then injected to artificially kick-start ovulation.

25
Q

What is ovarian diathermy?

A

Each ovary is monopolar diathermied at a few points for a few seconds. If successful, regular ovulations can continue for years.

26
Q

What are the side effects of ovulation induction?

A

Multiple pregnancies (clomifene and gonadotrophins).

Ovarian hyperstimulation syndrome (OHSS) - follicles get very large and painful. Can be life threatening. Seen in IVF and gonadotrophin treatment.

Ovarian and breast carcinoma.

27
Q

How is a man’s fertility tested?

A

Sperm analysis - if abnormal, repeat in 12 weeks.

28
Q

What are the common causes of abnormal semen?

A 
Smoking
Alcohol
Drugs - sulfazalazine and anabolic steroids 
Chemicals
Inadequate local cooling
Genetic factors
Antisperm antibody - common after vasectomy reversal
Infection 
Cystic fibrosis 
Retrograde ejaculation
29
Q

What are the main causes of tubal damage causing infertility?

A

Infection - chlamydia
Endometriosis
Surgery/adhesions

30
Q

What tests are used to detect tubal damage?

A

Laparoscopy and dye test - visualisation of the fallopian tubes and whether they are patent.
Hysterosalpingogram - radio-opaque contrast is injected through the cervix and spillage from the fimbrial ends can be seen on x-ray.

31
Q

What are the indications for assisted conception?

A 
When any/all other methods have failed
Unexplained subfertility 
Male factor subfertility (ICSI)
Tubal blockage (IVF) 
Endometriosis
Genetic disorders
32
Q

What methods are there for assisted conception?

A 
Intrauterine insemination
In vitro fertilisation (IVF)
Intracytoplasmic sperm injection
Oocyte donation
Preimplantation genetic diagnosis
Surrogacy
33
Q

Why does IVF not work for ovarian failure?

A

They don’t have ovarian reserve (follicles). This can be measured using AMH.

34
Q

What are the stages of IVF?

A
  1. Multifollicular development (using 2 weeks of daily subcutaneous gonadotrophin injections)
  2. Ovulation and egg collection (once enough follicles are large enough, LH or hCG is injected to finalise oocyte maturation and then 35-38 hours later the eggs are collected under sedation by US vaginally).
  3. Fertilisation and culture
  4. Embryo transfer (and then luteal support - using progesterone of hCG - is given until weeks 4-8)
35
Q

When do you use intracytoplasmic sperm injection instead of IVF?

A

When there are not enough motile sperm available to incubate a sufficiently high concentration with each oocyte standard for IVF.
Sperm is injected into the oocyte cytoplasm.

Becks Gynaecology Qs (14 decks)

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