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Gynaecology > Fertility and subfertility > Flashcards

Fertility and subfertility Flashcards

1
Q

Define subfertility

A

Couple are subfertile if conception has not occurred after a year of regular unprotected intercourse

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2
Q

Prevalence of subfertility

A

15%

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3
Q

Define infertility

A

Inability to concieve

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4
Q

Difference between primary and secondary subfertility

A

Never conceived vs conceived even if miscarriage/termination

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5
Q

What are the 4 conditions required for pregnancy?

A

1) Egg must be produced
2) Adequate sperm release
3) Sperm must reach egg
4) Fertilized egg must implant

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6
Q

What are the contributors to sub-fertility and their %

A 
Ovulatory problems 30%
Male problems 25%
Tubal problems 25%
Coital problems 5%
Cervical problems <5%
Unexplained (implantation?) 30%
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7
Q

Why does fertility decline with age?

A

Reduced genetic quality of remaining oocytes

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8
Q

What is mittelschmertz

A

Vaginal spotting, discharge or pelvic pain around ovulation

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9
Q

Clinical evidence of preovulation

A

1) Elevated serum progesterone in mid luteal phase (7days before menses)
2) Over the counter urine predictor kits shows LH surge

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10
Q

Fun scientific evidence of preovulation

A

Cervical mucus- fernlike patterns formed on dry slide and spinnbarkeit strings upto 15cm.
body temp drops 0.2 rises 0.5 in luteal

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11
Q

Define Polycystic ovary

A

Multiple small follicles in an enlarged ovary with regular cycles

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12
Q

Diagnostic criteria for Polycystic ovarian syndrome

A

2/3 criteria

1) PCO on US
2) Irregular periods >35d/ 5 weeks or more apart
3) Hirsutism: clinical (acne/excess body hair) or biochemical (increased testosterone)

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13
Q

Presentation of PCOS

A

Oligo/amenorrhoea, hirsutism, acne, obesity, increased rates of miscarriage, subfertility

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14
Q

How would you investigate for PCOS

A

FSH, LH, testosterone, prolactin, TSH
Fasting lipids and glucose
TVS«

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15
Q

Differentials for Anovulation (5)

A 
Hypothalamic disease- low FSH
Ovarian failure- high FSH
PCOS- normal FSH
Prolactinoma- 
Thyroid problems
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16
Q

Complications of PCOS (3)

A

Type 2 diabetes in 50%
Gestational diabetes 30%
Endometrial cancer (unopposed oestrogen)

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17
Q

Treatment of PCOS symptoms

A 
Cant treat subfertility
Advice to reduce weight
COCP but neet 3-4 bleeds to protect endometrium
Anti-androgens used for hirsutism
Cyproterone acetate/Spironolactone
Metformin-insulin sensitizer
Eflornithine- topical,
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18
Q

Hyperprolactinaemia can be caused by (4)

A

Pituitary adenomas/hyperplasia
PCOS
Hypothyroidism
Psychotropic drugs

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19
Q

How do you treat prolacinomas

A

Bromocriptime/cabergoline- dopamine agonists- restores ovulation because dopamine inhibits prolactin release
Surgery if fails

20
Q

Firstline treatment of PCOS and induction of ovulation by _, which is a _.

A

Clomifene 6 months days 2-6 antioestrogen blocking receptors in the hypothalamus and pituitary

21
Q

Secondline treatment for PCOS

A

Lifestyle and weight loss
Clomifene then…
1) Metformin-oral insulin sensitizing restores ovulation
2)Gonadotrophins- daily subcut recombinant urine purified FSH+/-LH with LH surge/bhCG after a 17mm follicle develops. Give if weight normal.
3) Laproscopic ovarian diathermy- each ovary is monopolar diathermied at a few points for a few seconds + checked for all other pathologies
4)GnRH pump
5)IVF

22
Q

Firstline ovulation treatment gives ovulation rate and live birth rates of

A

70% 40% (bad effect on endometrium)

23
Q

How is follicular growth monitored after admin of all these therapies?

A

US

24
Q

What are the side effects of ovulation induction

A

Multiple pregnancies
Ovarian hyperstimulation syndrome
Ovarian and breast carcinoma

25
Q

What is OHSS?

A

Follicles get very large and painful.

26
Q

Risk factors for OHSS

A

Gonadotrophin stimulation, age <35 years, previous OHSS and PCO

27
Q

How do you cancel an IVF cycle?

A

Withold the hCG injection

28
Q

Name the 4 terms that describe abnormal semen

A

Azoospermia, Oligospermia, Severe oligospermia, Asthenospermia

29
Q

Whats Azoospermia and how do you examine further

A

No sperm present,
Examine the presence of vas deferens
Check karyotype, cystic fibrosis, hormone profile (FSH,LH, testosterone, prolactin, TSH)
Surgical sperm retrieval then IVF + ICSI or donor insemination

30
Q

Whats Oligospermia/Severe

A

<5millon/mL- IVF +/- ICSI

31
Q

Whats Asthenospermia

A

Absent/low motility sperm

32
Q

How do you assess male fertility?

A

Semen analysis, repeated after 12 weeks if abnormal

33
Q

Congenital absence of vas deferens and subsequent azoospermia is due to what genetic condition?

A

Cystic fibrosis

34
Q

How do you manage male factor subfertility?

A

-General advice
-Specific measures eg subcut FSH/LH 6-12 months
-Assisted conception techniques-
IUI intrauterine insemination
ISCI-IVF intracytosplasmic sperm injection
SSR- Surgical sperm retrieval if azoospermia
DI- Donor insemination

35
Q

What could the causes for lack of fertilization be?

A

Mostly tubal damage (25%)- PID (STIs, IUS,ruptured appendix)
Cervical problems
Sexual problems

36
Q

What are the main causes of tubal damage?

A

PID-adhesions 12%
Endometriosis
Previous surgery/sterilization

37
Q

What are the main treatments for tubal damage?

A

Adhesiolysis/salpingostomy
Lap surgery for endometriosis
IVF/Microsurgical tubal reanastomosis for ligated tubes

38
Q

Cervical factors for subfertility are

A

Antibodies against sperm
Vagina/cervix infection which prevents mucus
Cone biopsy

39
Q

How does one overcome cervical factors of infertility

A

By pass the cervix by IUI

40
Q

How do you assess for tubal damage?

A

Hysteroscopy to check uterine cavity
Laparoscopy and dye test
HSG-hysterosalpingogram/TVS with HyCoSy

41
Q

Name a few types of assisted conception

A 
IUI- Interuterine insemination
IVF +/- ISCI- in vitro fertilization, intracytoplasmic sperm injection
FER- Frozen embryo replacement
Oocyte donation
PGD- Preimplantation genetic diagnosis
42
Q

Indications for assisted conception

A

Unexplained subfertility, male factor subfertility, tubal blockage, endometriosis, genetic disorders, all else has failed

43
Q

Whats stimulated IUI

A

gonadotrophin ovulation induction and then insemination

44
Q

Ovarian failure makes which method of assisted conception impossible

A

IVF

45
Q

How is ovarian reserve for IVF measured (2)

A

AMH-Anti mullerian hormone

TVS-AFC-Antral follicular count

46
Q

What are the complications of assisted conception?

A

Superovulation-multiple pregnancies and OHSS
Egg collection causes intraperitoneal hemorrhage and pelvic infection
Pregnancy complications- ectopics/perinatal mortality/

47
Q

How does fertility preservation measures differ in males and females in case of sterilizing disease/treatments?

A

Males can freeze samples, thawed and used during an IVF cycle.
Females have to freeze eggs (worse) or embryos. Male has right to withdraw consent even when woman then infertile.

Gynaecology (11 decks)

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