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Gynaecology > Fertility and Subfertility > Flashcards

Fertility and Subfertility Flashcards

1
Q

whats the definition of subfertility

A

inability to conceive after a year of unprotected intercourse

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2
Q

what is the prevalence of subfertility

A

15%

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3
Q

what are the 4 main ways in which fertility is affected and how do they affect

A

male factors (inadequate sperm release) - 25%
anovulation - 30%
malimplantation - 30%
sperm-egg not joining - 25% fallopian issue, 5% cervical issue, sexual issue 5%

%s add up to >100 because there is usually more than one issue

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4
Q

what does anti-mullerian hormone do

A

suppress oestrogen

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5
Q

how should you investigate a disordered ovulation cycle

A

Progesterone levels :
Elevated serum progesterone in mid-luteal phase suggests ovulation
Women with irregular cycles need this repeating

USS
Monitor corpus luteum and follicle
Raerely done

Urine predictor kit
Measures LH surge

Ovulation should follow

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6
Q

what is a polycystic ovary

A

appearance of multiple (>12) small (2-8mm) follicles in an enlarged ovary (>10ml)

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7
Q

what is the prevalence of polycystic ovaries (not PCOS) in women who regularly ovulate

A

20%

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8
Q

what is the diagnostic criteria for PCOS

A

2/3 of:

Polycystic ovaries on USS
irregular periods (>35 days apart)
Hirsutism (clinical or biochemical)
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9
Q

what is the pathology of PCOS

A

increased LH/peripheral insulin resistance leading to increased ovarian androgen production and reduced androgen binding products causing hirsutism and disregulated ovulation/folliculogenesis

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10
Q

what are the typical features of a patient with PCOS

A 
acne
overweight
hirsutism
amenorrhea/oligomenorrhea 
may have had miscarriages
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11
Q

how should you investigate PCOS

A

anovulation bloods: FSH (raised in ovarian failure, normal in PCOS)/AMH (raised in PCOS)/Prolactin/TSH

serum testosterone

LH (often raised but not diagnostic

Transvaginal USS

diabetes/lipids screen may be a good idea too

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12
Q

what are the complications of PCOS and the prevalence of the complications

A

t2dm - 50%
gestational diabetes - 30%
endometrial CA - 6x increase

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13
Q

what is the treatment for PCOS

A

weight reduction advice - 1st line

COCP if fertility not required - 1st line

anti-androgens (spironolactone, cytoproterone) - typically 2nd line

Clomifine - if fertility required

Metformin - if fertility required but normally used as a 1st line adjunct

eflornithine - topical anti-androgen used for facial hirsutism

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14
Q

what are some causes of anovulation

A 
hypothalamic hypogonadism 
kallman's syndrome 
hyperprolactinaemia 
premature ovarian insufficiency 
gonadal dysgenesis
lutenised unruptured follicle syndrome 
hyper/hypothyroidism 
androgen secreting tumours
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15
Q

what typically causes hypothalamic hypogonadism

A

anorexia
excess exercise
stress

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16
Q

what is Kallman’s syndrome

A

occurs when GnRH-secreting neurones fail to develop

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17
Q

how do you treat Kallman’s syndrome

A

exogenous gonadotrophins or GnRH pump

bone protection via COCP/HRT

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18
Q

what are features of hyperprolactinaemia

A

amenorrhea/oligomenorrhea
galactorrhea
headaches/bitemporal hemianopia if prolactinoma

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19
Q

what are the common causes of prolactinaemia

A 
prolactinoma of the pituitary
pituitary hyperplasia
hypothyroidism
PCOS
psychotropic drugs
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20
Q

how do you treat prolactinaemia

A

dopamine agonists (bromocriptine/cabergoline)

surgery if necessary

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21
Q

what blood results indicate premature ovarian insufficiency

A

high FSH/LH, low AMH

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22
Q

what is required when treating premature ovarian deficiency?

A

bone protection - via COCP/HRT

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23
Q

what is lutenised unruptured follicle syndrome + what is its progression

A

follicle develops but the egg is never released

unlikely to occur every month so not too much to worry about

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24
Q

how do you choose between clomifine and metformin when treating fertility in women with PCOS

A

metformin works better in patients with a BMI <30 and can be used for longer - clomifine is limited to 6 months use

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25
Q

when in the menstrual cycle is clomifine best given

A

2-6 days

26
Q

how should you follow up the use of clomifine in PCOS

A

transvaginal USS to asses endometrial thickness (causes thinning) and follicular development

none = up dose
>3 = reduce dose
27
Q

what is an alternative surgical procedure for PCOS

A

laporoscopic ovarian diathermy

28
Q

what are side effects of ovulation treatment/induced ovulation

A

multiple pregnancy

ovarian hyperstimulation syndrome

29
Q

what is on ovarian hyperstimulation syndrome

A

overgrowthof the follicles which can cause considerable pain

30
Q

what are some risk factors for the development of ovarian hyperstimulation syndrome whilst taking gonadotrophins

A

<35

previous OHSS + PCO

31
Q

what are complications/severe symptoms of ovarian hyperstimulation syndrome

A 
hypovolaemia
electrolyte disturbance 
ascites
thromboembolism
pulmonary oedema
32
Q

what hormone is spermatogenesis mainly reliant on

A

LH (testosterone) and FSH

33
Q

how does LH and FSH affect spermatogenesis and what cells do they act on

A

LH controls hormone production via leydig cells

FSH/testosterone controls sperm production and transport via sertoli cells

34
Q

how long does it take sperm to develop fully grown sperm

A

70 days

35
Q

what are the components of semen analysis and their normal ranges

A

volume of semen - 1.5ml
sperm count - >15million/ml
progressive motility - >32%

36
Q

what is the definition of azoospermia

A

no sperm present

37
Q

what is the definition of oligospermia

A

<15million/ml

38
Q

what is the definition of severe oligospermia

A

<5million/ml

39
Q

what is the definition of asthenospermia

A

absent or low motility

40
Q

what may cause abnormal/absent sperm release

A 
idiopathic
drug exposure - alcohol, smoking, sulfasalazine, anabolic steroids 
varicocele 
anti-sperm antibodies 
infections
genetic abnormalities 
hypothalamic issues
kallmans syndrome 
hyperprolactinaemia 
retrograde ejaculation
41
Q

how should you investigate azoospermia

A

azoospermia - FSH, LH, Testosteronem prolactin and TSH:
hypothalamic hypogonadism - low LH/FSH/testosterone
hyperprolactinaemia/thyroid issues are relative obvious
primary testicular failure - high FSH and LH, low testosterone

serum karyotyping - e.g. XXY in kleinfelters

cystic fibrosis testing if absent vas deferens

42
Q

how should you manage male subfertility

A

General advice:
Stop smoking/drinking
Avoid aggravating drugs
Wear loose clothing to prevent testicular heating

Specific measures

Hypogonadotropic hypogonadism can be treated with 6-12 months of exogenous FSH/LH (+/- HCG) injections 3x a week

Assisted conception

43
Q

what is the protocol for artificial insemination with male infertility

A

Intrauterine insemination works for mild-moderate oligospermia

IVF is reserved for more severe oligospermia

Intracytoplasmic sperm injection (ICSI) is used as part of the IVF cycle for even more severe cases

Surgical sperm retrieval may be used if there is azoospermia then use ICSI-IVF

44
Q

what are some common causes of failure to join the sperm to egg (failure to fertilise)

A 
PID 
Endometriosis - 25% of all subfertile women 
Previous pelvic surgery/sterilisation 
cervical problems - rare 
sexual problems
45
Q

what are the options for detecting tubal damage when investigating failure to fertilise

A

Laparoscopy and dye test
Methylene blue injected into cervix and tubes are observed
If dye spills out they are patent , if it doesn’t they are not

Hysterescopy
Performed to assess any uterine abnormalities

Hysterosalpingogram
Radio-opaque dye injected into the cervix
Fimbral spilling seen on xray
Less invasive version done with a transvaginal USS but this does not pick up endometriosis or periovarian adhesions

46
Q

what are the current types of assisted conception

A 
Intrauterine insemination 
IVF +/- in vitro fertilisation 
frozen embryo replacement 
oocyte donation 
preimplantation genetic diagnosis
47
Q

what is intrauterine insemination

A

washed sperm are injected directly into the uterine cavity

performed during a natural ovarian cycle - identified by urinary LH testing

48
Q

what kinds of couples is intrauterine insemination right for

A

Unexplained subfertility

Sexual issues

Cervical problems

Male factor problems

49
Q

whats the live birth rate for intrauterine insemination

A

10-15%

50
Q

what is in vitro fertilisation +/- intracytoplasmic sperm injection

A

embryos are fertilised outside the uterus and implanted back in

51
Q

what is the age stratified live birth rate for IVF +/- ICSI

A

<36 - 35%

40 - <10%

52
Q

what is required of the ovaries before IVF may be started, and how is this measured

A

a normal ovarian reserve - meaning it cant be done in those with ovarian failure

anti-mullerian hormone

53
Q

what are the 4 stages of IVF

A

multiple follicular development
ovulation and egg collection
fertilisation and culture
embryo transfer

54
Q

what are the different protocols for the multiple follicular development stage of IVF

A

Long Protocol
2-3 weeks of GnRH is used to suppress the pituitary FSH/LH production and cause ovarian suppression

Once suppression is confirmed by endometrial thinning or low oestrogen levels FSH/LH can begin

The GnRH is continued until follicle collection

Short protocol
Pituitary suppression not achieved before FSH/LH injections

Instead a GnRH antagonist is added 5 days into the FSH/LH regime and continued until collection

55
Q

what is used to mature follicles for IVF

A

bHCG or LH

56
Q

what is the twin pregnancy rate for IVF

A

25%

57
Q

what should be given to women before they take in donated oocytes

A

oestrogen and progesterone to prepare her endometrium

58
Q

what is preimplantation genetic diagnosis used for

A

couples with known genetic abnormalities

59
Q

what are complications of assisted conception

A

superovulation - multiple pregnancy and ovarian stimulation

egg collection - intraperitoneal infection and haemorrhage are risk of this procedure (only 1%)

pregnancy complications - increased rate of ectopic pregnancy

60
Q

what is the live birth rate for a single IVF cycle with frozen eggs

A

30-50% (<37yrs)

Gynaecology (14 decks)

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