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O&G > Fertility, subfertility and contraception > Flashcards

Fertility, subfertility and contraception Flashcards

1
Q

Why do people with PCOS have anovulation/oligoovulation?

A

Increased androgen production → increased LH secretion → disrupted LH/FSH balance → impaired follicle maturation

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2
Q

What is the difference between ovarian insufficiency and premature menopause?

A

Insufficiency: IMPAIRED functional capacity

Menopause: complete loss of ovarian function

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3
Q

Why do women with ovarian insufficiency have high FSH and LH?

A

Impaired follicular development → low oestrogen → loss of inhibition on FSH and LH

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4
Q

What is the definition of primary amenorrhoea?

A

Absence of menses at the age of 15 or order

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5
Q

What is the definition of secondary amenorrhoea?

A

Absence of menses for more than 3 months in women with previously regular cycles or 6 months in women with previously irregular cycles

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6
Q

What is the definition of oligomenorrhoea?

A

Menstrual cycle with intervals of 35-90 days

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7
Q

What is the definition of infertility?

A

Inability of a couple to conceive despite one year of unprotected sex

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8
Q

When in the menstrual cycle is the onset of pain from PID most common?

A

During or shortly after menses

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9
Q

How is ovarian insufficiency diagnosed?

A

Elevated FSH after 3 months of amenorrhoea in a women under 40

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10
Q

What is the only risk factor for ovarian ectopic pregnancies?

A

Intrauterine devices

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11
Q

What is the strongest predictor of failure of methotrexate therapy for ectopic pregnancy?

A

HIgh serum hCG

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12
Q

What is the medical treatment regimen for spontaneous abortion?

A

200mg oral mifepristone followed by 800mcg of misprostol intravaginally

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13
Q

What is the mechanism of mifepristone?

A

Progesterone antagonist

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14
Q

What is the function of misoprostol?

A

Prostaglandin E1 analogue

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15
Q

What is the most common cause of miscarriage?

A

Foetal chromosomal abnormalities (50%)

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16
Q

When can an ectopic pregnancy be managed expectantly?

A
  1. Patient in minimal pain
  2. Decreasing bHCG
  3. Diagnosis in doubt
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17
Q

What BhCG level is considered safe for medical management of an ectopic pregnancy?

A

< 5000

Women with a higher hCG are more likely to require multiple courses of MTX therapy or experience treatment failure

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18
Q

What is the main mechanism of the COCP?

A

Suppression of follicle development and ovulation

  • Makes cervical passage more hostile for spermatozoa*
  • Blocks implantation by altering the endometrial lining*
  • Inhibits tubal peristalsis*
  • Thickens cervical mucous to form a barrier to sperm*
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19
Q

Which class of drugs reduces the effectiveness of the COCP?

A

Anticonvulsants

Alternative options or higher doses should be considered

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20
Q

What is the efficacy of levonorgestrel emergency contraception?

A

89% if taken within 72 hours

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21
Q

What is the efficacy of ulipristal (selective progesterone receptor modular) as emergency contraception?

A

90% if taken within 5 days

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22
Q

What is the mechanism of clomiphene citrate?

A

Inhibits hypothalamic estrogen receptors → blocks normal negative feedback of estrogen → increased pulsatile secretion of GnRH → increased LH and FSH

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23
Q

How is anovulation diagnosed?

A

No rise in serum progesterone 7 days before onset of menses

Progesteone should rise shortly after ovulation

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24
Q

How are uterine and tubal abnormalities screened?

A

Hysterosalpingography

Given the woman has no history of pelvic infections, endometriosis or ectopic pregnancy

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25
Q

How is sex hormone binding globulin affected by PCOS?

A

Increased insulin → decreased hepatic synthesis of SHBG → elevated free androgen → hyperandrogenism

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26
Q

How is PCOS diagnosed?

A

2/3 of the following:

Hyperandrogenism

Oligo- and/or anovulation

Polycystic ovaries on ultrasound

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27
Q

What is the most common site of involvement in endometriosis?

A

Ovary

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28
Q

Endometriosis located at the { } will present as pain with defectation

A

Pouch of Douglas

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29
Q

What is the most important risk factor for ectopic pregnancy?

A

Anatomic alteration to the fallopian tubes

E.g. PID, endometriosis, surgery, previous ectopic

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30
Q

What is the definition of infertility?

A

Inability to convieve after 12 months of unprotected sex for women < 35 and 6 months in women > 35

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31
Q

What is the definiton of primary infertility?

A

The couple has never been able to concieve

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32
Q

What is secondary infertility?

A

The couple meets the definition of infertility but has conceived before

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33
Q

How is ovarian reserve assessed?

A

Day 3 FSH and estradiol levels

AMH levels

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34
Q

What is the usefulness of measuring a woman’s anti-mullerian hormone levels?

A

Marker of ovarian reserve

Expressed by small preatral and early antral follicles

Reflects the size of the primordial follicle pool

Levels decline as the primordial follicle pool declines with age until it is undetectable at menopause

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35
Q

Why might spironolactone be given to a woman with PCOS?

A

Antiandrogenic properties

Competes with dihydrotestosterone (pre-testosterone) for binding to the androgen receptor and inhibits enzymes involved in androgen biosynthesis

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36
Q

How are chocolate cysts formed?

A

Cystic bleeding (menstruation) of the ectopic endometrial tissue results in cysts filled with blood that have a chocolate appearance

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37
Q

What is the aetiology of increased serum testosterone in a woman with PCOS?

A

Increased estrogen → increased LH → theca cell stimulation → increased androgen production

Increased LH relative to FSH → decreased conversion of testosterone to oestrogen

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38
Q

PCOS is a risk factor for which cancer?

A

Endometrial

Increased oestrogen

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39
Q

When in their cycle are females fertile?

A

Ovulation and the 5-6 days prior (sperm can survive 5 days)

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40
Q

Why might short cycles impair a woman’s ability to conceive?

A

Shortened follicular phase → impaired follicular development

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41
Q

When is letrozole used for infertility?

A

Aromatase inhibitor

Used in PCOS

→ decreases testosterone → decreases oestrogen → no suppression of FSH → follicle development

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42
Q

How does metformin improve fertility in women with PCOS?

A

Decreased insulin → decreased androgen → decreased oestrogen → reduced suppression of FSH → follicle development

43
Q

Why does endometriosis cause infertility?

A

Shedding of endometrial tissue in the adenexae → inflammation → scarring

44
Q

What is a normal sperm count? (sperm/mL)

A

15 million

45
Q

Why does hyperprolactinaemia cause infertility?

A

Prolactin inhibits GnRH release

46
Q

What is idiopathic dysspermatogenesis?

A

Abnormalities in sperm number, morphology and/or motility with no identifiable cause

Most common primary testicular defect

47
Q

What is the genetic abnormality in Klinefelter syndrome?

A

XXY

Impaired spermatogenesis + low testosterone + small testes → infertility

48
Q

Name 3 causes of aquired testicular defects which may cause male infertility

A
  1. Varicocele (pampiniform plexus dilation)
  2. Infection (germinal cell damage)
  3. Radiation
  4. Chemotherapy + hormonal therapy
  5. Anti-sperm antibodies
49
Q

Name 3 sperm transport disorders which may lead to male infertility

A
  1. Bilateral vas deferens obstruction
  2. Primary ciliary dyskinesia
  3. Retrograde ejaculation (failure of bladder sphincter)
  4. Erectile dysfunction/premature ejaculation
50
Q

How is fertility 2o to a prolactin adenoma treated?

A

Dopamine agonist therapy (cabergoline)

Dopamine inhibits prolactin secretion from the anterior pituitary

51
Q

Name 2 assisted reproductive technologies

A
  1. Intrauterine insemination (IUI) - gives the sperm a “head-start”
  2. In-vitro fertilisation
  3. IVF with intracytoplasmic sperm injection
52
Q

How does increased insulin lead to hyperandrogenism?

A
  1. Stimulates theca cells
  2. Decreased hepatic sythesis of SHBG
53
Q

What is the traditional regimen for starting contraception (OCPs, vaginal rings, implants, Depo)?

A

Start during menses

Excludes pregnancy and contraception is effective immediately

54
Q

If a patient is sick (e.g., vomiting, diarrhoea) while on the pill, how long until they are protected again?

A

7 days

55
Q

Of levonorgestrel, ulipristal and the copper IUD, which is the most effective emergency contraception?

A

Copper IUD

56
Q

For it to be effective, how long can you wait after unprotected sex to have a copper IUD?

A

5 days

Or up to day 12 of the menstrual cycle because of intertility before this point

57
Q

What is the main MoA of the Depo injection, Mirena and Implanon?

A

Prevention of ovulation

58
Q

How should breakthrough bleeding on continuous contraception methods be managed?

A

3-4 day hormone-free intervals

59
Q

Which contraceptive methods are most associated with a worsening of acne?

A

Progestin-only

60
Q

Amenorrhoea is most associated with which contraceptives?

A

Mirena

Implanon

Depo-Provera

61
Q

Heavy menses are most strongly associated with which contraceptive methods?

A

Depo-Provera

Implanon

62
Q

Decreased libido is most associated with which contraceptives?

A

Very low-dose combined oral contraceptives

63
Q

Hirsutism is most strongly associated with which contraceptives?

A

Progestin-only

64
Q

Increased vaginal discharge is most associated with which contraceptive?

A

Vaginal ring (Nuvaring)

All contraceptives can have this effect, however

65
Q

Weight gain is most strongly associated with which contraception?

A

Depo-Provera

(20% of women)

66
Q

Which contraceptives should be avoided in women who are breastfeeding and less than 6 months postpartum?

A

COCs

Nuvaring

67
Q

For how long following birth is the OCP contraindicated?

A

6 weeks

68
Q

When is smoking a contraindication for the OCP?

A

Smoker (>15 cigarettes per day) over the age of 35

69
Q

What blood pressure is a contraindication to the OCP?

A

SBP > 160 mmHg

OR

DBP > 100 mmHg

70
Q

In women who do not breastfeed, how long postpartum does ovulation resume?

A

Mean: 39 days (~6 weeks)

71
Q

In women who breastfeed, when does ovulation resume?

A

27-38 weeks

(around 7-9 months)

72
Q

When can an IUD be inserted after delivery?

A

Within 48 hours, otherwise 28 days

73
Q

What endometrial thickness suggests a complete abortion?

A

<15mm

74
Q

What is a subchorionic haematoma?

A

Haematoma formed between the chorion and uterine wall

Caused by separation of the endometrium from the chorion

Risks: miscarriage, stillbirth, preterm labour

75
Q

What is the incidence of gestastional trophoblastic neoplasia following a hydatidiform mole?

A

Complete: 15-20%

Partial: 1-5%

76
Q

What are some of the common symptoms associated with pelvic inflammatory disease, which you must ask about in a history?

A

Pelvic or lower abdominal pain usually bilateral

Deep dyspareunia

Dysmenorrhoea

Abnormal or increased vaginal discharge

Fever

77
Q

What are the features of Fitz-Hugh-Curtis syndrome?

A

Perihepatitis (RUQ pain)

Complication of PID

78
Q

Which organism causes syphilis?

A

Treponema pallidum

79
Q

What is the treatment for syphilis?

A

Benzathine penicillin

80
Q

What is the Jarisch-Herxheimer reaction?

A

A reaction sometimes seen following treatment of syphilis. It is thought to be due to the release of endotoxins following bacterial death.

81
Q

What are the clinical features of the Jarisch-Herxheimer reaction?

A

Flu-like symptoms: fever, chills, headache, myalgia

Tachypnea, hypotension, and tachycardia

Exanthem

82
Q

What is considered frequent enough sexual intercourse in order to have a good chance of conceiving?

A

Every 2-3 days

83
Q

What blood tests would you order when investigating female infertility?

A

Mid-luteal progesterone

Prolactin

Androgens

FSH

Oestrogen

TSH

84
Q

What are the normal parameters in semen analysis?

A

Volume: >1.5mL

Count: >15 million/mL

Morphology: >4% normal forms

Vitality: > 58% live

85
Q

What are the most important risks associated with clomiphene use?

A

Multiple prenancy

Ovarian hyperstimulation syndrome

86
Q

What is intracytoplasmic sperm injection (ICSI)?

A

Advanced form of IVF where one sperm is directly injected into the egg

87
Q

What is ovarian hyperstimulation syndrome?

A

Fertility treatments → ovarian hyperstimulation → increased vascular permeability → third space fluid loss, mainly to the abdominal cavity

→ thromboembolic events e.g. stroke

88
Q

What weeks of gestation make up the second trimester?

A

13-27 weeks

89
Q

What weeks of gestation make up the third trimester?

A

28-40 weeks

90
Q

After how many miscarriages would you start to investigate the cause of miscarriage?

A

3

91
Q

What further tests can be performed for a couple who have had recurrent (more than 3 consecutive) miscarriages?

A

Sonohysterography for assessment of uterine abnormalities

Anticardiolipin antibody (IgG and IgM) titer and lupus anticoagulant performed twice, six to eight weeks apart

Thyroid stimulating hormone (TSH) and thyroid peroxidase antibodies

Parental karyotype and karyotype of the abortus if the above examinations are normal.

92
Q

What investigation is used to assess tube patency in an infertile woman?

A

Hysterosalpingogram

Intra-uterine x-ray

93
Q

Why isn’t exogenous testosterone used in hypogonadic infertile patients?

A

Spermatogenesis requires some level of intratesticular testosterone

Exogenous testosterone inhibits LH and therefore intratesticular testosterone

94
Q

A unilateral or bilateral absence of the vas deferens could suggest which condition?

A

Cystic fibrosis

Testing for CFTR gene mutation is indicated

95
Q

Can vasectomies be reversed?

A

Yes

But less likely with time from surgery

96
Q

What is the mechanism of action of the copper IUD?

A

Mild foreign body reaction in endometrium → toxic to sperm and alters sperm motility

97
Q

What is the most common site for an ectopic pregnancy?

A

Ampulla of the fallopian tube (70%)

98
Q

What is the most common cause of male infertility?

A

Varicocele

99
Q

When do OCPs become effective?

A

Immediate if initiated on day 1-5 of the menstrual cycle

Otherwise combined require 7 days and progesterone-only 3 days

100
Q

When do the implanon and mirena become effective?

A

Immediate if day 1-5 of menstrual cycle

Otherwise 7 days

101
Q

For which cancers is the COCP a risk factor?

A

Breast

Cervical

102
Q

For which cancers is the COCP protective?

A

Endometrial

Ovarian

103
Q

How can a missed miscarriage be medically managed?

A

Intravaginal misoprostol

(mifepristone is not needed as progesterone levels are already low)

O&G (13 decks)

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