Fertility/infertility

Question 1

Indications for myomectomy in infertile women

Answer 1

1. Undergoing ART with SM fibroids
2. symptomatic fibroid(s), such as heavy vaginal bleeding or pressure sx (even though trial evidence does not show clear fertility benefit, the presence of sx may justify)
3. Multiple failed cycles of ART with IM fibroids

Question 2

Ethics of CBRC (cross-border reproductive care)

Answer 2

1. health and safety
   - the health and safety of all parties (patient, offspring, third party [i.e. gamete or embryo donors and/or gestational carriers]), practitioners facilitating CBRC) must be the guiding principle. If the health and safety of any party is compromised by an intervention, this cannot be supported (e.g. unacceptable risk of transmission of infectious disease or the creation of high order multiple pregnancies)
2. autonomy
   - all parties must be adequately counselled.
3. Equity
   - same info & counselling & support provided to all parties
   - mechanisms to ensure equity of access

Question 3

Serum AMH

Answer 3

• Generally peaks between age 20-25 y
• Is lower in those with a higher BMI
• May be suppressed by current or recent COCP use
• May vary across the menstrual cycle

Question 4

Clomiphene MOA

Answer 4

SERM (selective oestrogen receptor modulator)
- Acts centrally to block effects of oestrogen at the level of the hypothalamus by binding to oestrogen receptors.
- Results in increased pulsatile GnRH from hypothalamus -> increased FSH and LH from the ant pituitary
- FSH = dominant follicle maturation = high levels of oestrogen produced from granulosa cells surrounding dominant follicle = switch from negative to positive feedback effect on the anterior pituitary = LH surge -> ovulation

Question 5

First cycle clomiphene citrate

Answer 5

1. Determine LMP and cycle length
2. If irregular periods/amenorrhoea then withdrawal bleed with 14 days progesterone
3. Start with 50mg clomiphene D2-7 of cycle
4. D10 USS to check developing follicle numbers. If >2 dominant follicles, then adhere to local protocols re withdrawing UPSI (reduce risk OHSS)
5. UPSI every other day from 5 days after last dose clomiphene
   –> LH surge 5-12 days after last dose clomiphene
   –> Ovulation 12-36 h after LH surge
   (can also use ovualtion testing kits)
6. Midluteal progesterone 7 days after ovulation
   –> if ovulation confirmed, then correct dosage
   –> if no ovulation, may need increased dose
7. If period then consider increased dose next cycle. If no period then HCG

Question 6

Subsequent clomiphene cycles (assuming not pregnant)

Answer 6

• Increased by 50mg each cycle (to a max of 150mg/day) until ovulation achieved
• Continue required dose to achieve ovulation for 4-6 cycles
• Max of 12 cycles of clomiphene
  –> pregnancy rate low if not pregnant after 6 ovulatory cycles

Question 7

Side effects/risks clomiphene

Answer 7

• 10% risk of multiples
• Abdominal pain and bloating
• OHSS
• Failure to induce ovulation/conceive pregnancy
• headaches
• Nausea and vomiting