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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
when in the menstrual cycle is clomifine best given
2-6 days
26
how should you follow up the use of clomifine in PCOS
transvaginal USS to asses endometrial thickness (causes thinning) and follicular development ``` none = up dose >3 = reduce dose ```
27
what is an alternative surgical procedure for PCOS
laporoscopic ovarian diathermy
28
what are side effects of ovulation treatment/induced ovulation
multiple pregnancy | ovarian hyperstimulation syndrome
29
what is on ovarian hyperstimulation syndrome
overgrowthof the follicles which can cause considerable pain
30
what are some risk factors for the development of ovarian hyperstimulation syndrome whilst taking gonadotrophins
<35 | previous OHSS + PCO
31
what are complications/severe symptoms of ovarian hyperstimulation syndrome
``` hypovolaemia electrolyte disturbance ascites thromboembolism pulmonary oedema ```
32
what hormone is spermatogenesis mainly reliant on
LH (testosterone) and FSH
33
how does LH and FSH affect spermatogenesis and what cells do they act on
LH controls hormone production via leydig cells FSH/testosterone controls sperm production and transport via sertoli cells
34
how long does it take sperm to develop fully grown sperm
70 days
35
what are the components of semen analysis and their normal ranges
volume of semen - 1.5ml sperm count - >15million/ml progressive motility - >32%
36
what is the definition of azoospermia
no sperm present
37
what is the definition of oligospermia
<15million/ml
38
what is the definition of severe oligospermia
<5million/ml
39
what is the definition of asthenospermia
absent or low motility
40
what may cause abnormal/absent sperm release
``` idiopathic drug exposure - alcohol, smoking, sulfasalazine, anabolic steroids varicocele anti-sperm antibodies infections genetic abnormalities hypothalamic issues kallmans syndrome hyperprolactinaemia retrograde ejaculation ```
41
how should you investigate azoospermia
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
how should you manage male subfertility
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
what is the protocol for artificial insemination with male infertility
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
what are some common causes of failure to join the sperm to egg (failure to fertilise)
``` PID Endometriosis - 25% of all subfertile women Previous pelvic surgery/sterilisation cervical problems - rare sexual problems ```
45
what are the options for detecting tubal damage when investigating failure to fertilise
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
what are the current types of assisted conception
``` Intrauterine insemination IVF +/- in vitro fertilisation frozen embryo replacement oocyte donation preimplantation genetic diagnosis ```
47
what is intrauterine insemination
washed sperm are injected directly into the uterine cavity performed during a natural ovarian cycle - identified by urinary LH testing
48
what kinds of couples is intrauterine insemination right for
Unexplained subfertility Sexual issues Cervical problems Male factor problems
49
whats the live birth rate for intrauterine insemination
10-15%
50
what is in vitro fertilisation +/- intracytoplasmic sperm injection
embryos are fertilised outside the uterus and implanted back in
51
what is the age stratified live birth rate for IVF +/- ICSI
<36 - 35% | 40 - <10%
52
what is required of the ovaries before IVF may be started, and how is this measured
a normal ovarian reserve - meaning it cant be done in those with ovarian failure anti-mullerian hormone
53
what are the 4 stages of IVF
multiple follicular development ovulation and egg collection fertilisation and culture embryo transfer
54
what are the different protocols for the multiple follicular development stage of IVF
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
what is used to mature follicles for IVF
bHCG or LH
56
what is the twin pregnancy rate for IVF
25%
57
what should be given to women before they take in donated oocytes
oestrogen and progesterone to prepare her endometrium
58
what is preimplantation genetic diagnosis used for
couples with known genetic abnormalities
59
what are complications of assisted conception
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
what is the live birth rate for a single IVF cycle with frozen eggs
30-50% (<37yrs)

Gynaecology (14 decks)

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