Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Yr4: Obstetrics & Gynaecology > Gynae: Fertility > Flashcards

Gynae: Fertility Flashcards

1
Q

Define infertility

A

“A disease of the reproductive system defined by failure to achieve a pregnancy after 12 months or more of regular unprotected sex (without contraception) between a man and a woman” British Fertility Society

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Infertility can be classed as primary or secondary; explain the difference

A
  • Primary: couple never been able to conceive
  • Secondary: couple cannot conceive again despite previously having been able to without difficulty
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Discuss what proportion of couples will struggle to conceive naturally

A

1 in 7 couples struggle to conceive naturally

80% of couples will conceive naturally withing 1 year of regular unprotected sex if woman is under 40yrs. If don’t conceive in first year, 50% will go on to conceive in next yeawr

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What do we mean by regular unprotected sex?

A

Having regular sex means having sex every 2 to 3 days throughout the month without any contraception

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What should you explore in history of couple presenting with infertility/subfertility?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

State some modifiable lifestyle risk factors for infertility/subfertility

A
  • Smoking
  • Obesity
  • Excess alcohol
  • Stress
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

When/at what point should you investigate and refer to infertility?

*HINT: think about any exceptions to this rule

A
  • When couple have been trying to conceive without success for 12 months
  • Can be reduced to 6 months is woman >35yrs (ovarian function likely reduced hence more time pressure)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

State some potential causes of infertility/subfertility

A
  • Sperm problems (30%)
  • Ovulation problems (25%)
  • Tubal problems (15%)
  • Uterine problems (10%)
  • Unexplained (20%)

40% of infertile couples have a mix of male and female causes.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What investigations may be performed in primary care for infertility?

A

Investigations in female:

  • BMI: low could indicate anovulation, high could indicate PCOS
  • Female hormone testing: see separate FC for details
  • Chlamydia screening

Investigations in male:

  • Semen analysis
  • Chlamydia screening:

?????Rubella immunity in mother: not mentioned in NICE but mentioned in ZtoF????

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What hormones are tested as part of ‘female hormone testing’?

For each, discuss (if relevant) when in cycle test should be taken and what tests indicate

A
  • LH & FSH: days 2-5 of cycle
  • Progesterone: on day 21 (or 7 days before end of cycle if cycle not 28 days) to confirm ovulation
  • Anti-Mullerian hormone: measure at any time in cycle, most accurate measure of ovarian reserve. High level indicates good ovarian reserve.
  • TFTs: when symptoms suggest thyroid disease
  • Prolactin: in women with an ovulatory disorder, galactorrhoea, or a suspected pituitary tumour
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Where is Anti-Mullerian hormone released from?

A

Granulosa cells of follicles

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What further investigations may be performed in secondary care for infertility/subfertility in females- for each state why it may be done?

A
  • Ultrasound pelvis: investigate for PCOS and other structural abnormalities of uterus
  • Hysterosalpingogram: assess fallopian tube patency
  • Laparoscopy & dye test: assess for fallopian tube patency, adhesions & endometriosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

For a hysterosalpingogram, discuss:

  • What it can assess
  • What it involves
  • Screening required before procedure
  • Benefits
  • There is a risk of…?
  • Precaution taken to reduce risks
A
  • Scan used to assess shape of uterus and patency of fallopian tubes
  • Insert small tube into cervix, inject contrast medium which fills uterine cavity and fallopian tubes, take x-ray images, contrast shows up on scan showing you shape of uterus and patency of tubes
  • Chlamydia & gonorrhoea screening required prior to procedure
  • Benefits:
    • Diagnostic
    • Seems to increase rate of conception without other interventions
    • Tubal cannulation under x-ray guidance can be performed during procedure to open up tubes
  • Risk of infection
  • Prophylactic abx for pts with dilated tubes or hx pelvic infection
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

For laparoscopy and dye test, discuss:

  • What it involves
  • What it assesses
A
  • Assesses for:
    • Tubal patency
    • Endometriosis
    • Pelvic adhesions
  • Admit pt. Inject dye into uterus. Should see dye spill out at ends of fallopian tubes; if not seen means there is tubal obstruction. May also be able to treat endometriosis and pelvic adhesions during procedure.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Discuss general lifestyle advice that can be given to couples trying to conceive

A
  • Healthy BMI- weight loss or weight gain
  • Smoking cessation
  • Avoid excess alcohol
  • Reduce stress (can negatively impact libido and relationship)
  • Aim for intercourse every 2-3 days
  • Avoid timing intercourse
  • Take 400mcg folic acid daily
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Is timed intercourse recommended?

A

Not recommended by NICE as it can lead to increased stress & pressure in relationship

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Discuss some management options for anovulation

A
  • Weight loss: weight loss in overweight PCOS pts can restore ovulation
  • Clomifene: stimulate ovulation
  • Letrozole: can be used instead of clomifene to stimulate ovulation and help weight loss
  • Gonadotropins: stimulate ovulation in women resistant to clomifene
  • Ovarian drilling: may be used in PCOS
  • Metformin: can be used if there is insulin insensitivity and obesity (often associated with PCOS)
  • Dopamine agonists: in women with anovulation secondary to hyperprolactinaemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

For clomifene, discuss:

  • Mechanism of action
  • When in cycle it is given
  • ADRs
A
  • Anti-oestrogen SERM (oestrogen receptor antagonist) which stops negative feedback of oestrogen on hypothalamus resulting in increased GnRH and subsequent FSH and LH release
  • Give on days 2-6 of cycle
  • ADRs:
    • Flushing
    • Nausea
    • Headache
    • Breast discomfort
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What does ovarian drilling involve?

A

Laparoscopic surgery in which surgeon puts multiple holes in ovaries using diathermy or laser therapy. Can improve hormone profile and result in regular ovulation & fertility.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Discuss some management options for tubal factors causing subfertility/infertility

A
  • Tubal cannulation during hysterosalpingogram
  • Laparoscopy to remove adhesions or endometriosis
  • IVF
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Discuss some management options for uterine factors causing infertility/subfertility

A

Most management is surgery of some sort to correct polyps, structural abnormalities, adhesions etc…

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Discuss some management options for sperm problems causing infertility/subfertility

A
  • Surgical sperm retrieval: if there is a blockage in vas deferens a needle & syringe can be used to collect sperm from epididymis through scrotum
  • Surgical correction of obstruction of vas deferens
  • Intra-uterine insemination: collecting and separating out high quality sperm then injecting directly into uterus (NOTE: unclear whether better than normal intercourse)
  • Intracytoplasmic sperm injection (ICSI): inject sperm directly into cytoplasm of egg to form embryo then implant embryo in uterus. Useful if there are sperm mobility issues, low sperm counts or other sperm issues
  • Donor insemination: sperm from a donor
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

When we take a sample of semen for semen analysis, what are assessing for?

A

Quantity and quality of semen & sperm (to assess for male factor infertility)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

State some factors that may affect results of semen analysis

A

Several lifestyle factors may affect the results of semen analysis and the quality and quantity of sperm:

  • Hot baths
  • Tight underwear
  • Smoking
  • Alcohol
  • Raised BMI
  • Caffeine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What advice should you give to men in regards to providing a semen sample?

A
  • Abstain from ejaculation for at least 3 days and at most 7 days
  • Avoid hot baths, sauna and tight underwear during the lead up to providing a sample
  • Attempt to catch the full sample
  • Deliver the sample to the lab within 1 hour of ejaculation
  • Keep the sample warm (e.g. in underwear) before delivery
26
Q

What is the semen sample tested for in semen analysis? (i.e. what parameters)

A
  • Semen volume: more than 1.5mL
  • Semen pH:>7.2
  • Concentration of sperm:>15million per mL
  • Total number of sperm: >39 million per sample
  • Mobility of sperm:>40% are mobile
  • Vitality of sperm: >58% are active
  • Percentage of normal sperm: >4%
27
Q

Define:

  • Polyspermia (or polyzoospermia)
  • Normospermia (or normozoospermia)
  • Oligospermia (oligozoospermia)
  • Cryptozoospermia
  • Azoospermia
A
  • Polyspermia (or polyzoospermia): high number of sperm/ >250million per mL
  • Normospermia (or normozoospermia): normal characteristics of sperm in semen sample
  • Oligospermia (oligozoospermia): reduced number of sperm
    • Mild: 10-15 million/mL
    • Moderate: 5-10 million/mL
    • Severe: <5 million/mL
  • Cryptozoospermia: < 1 million sperm/mL
  • Azoospermia: absence of sperm in semen
28
Q

When is a repeat sample indicated in semen analysis?

A
  • Borderline results → repeat after 3 months (to allow time for cycle of spermatozoa to be completed)
  • Very abnormal results → repeat after 2-4 weeks
29
Q

Male factor infertility causes can be grouped into three broad categories: pre-testicular, testicular and post-testicular causes. State some pre-testicular causes

A

Hypogonadotropic hypogonadism:

  • Pathology of hypothalamus or pituitary
  • Suppression of HPG axis due to stress, chronic conditions, hyperprolactinaemia
  • Kallman syndrome
30
Q

Male factor infertility causes can be grouped into three broad categories: pre-testicular, testicular and post-testicular causes. State some testicular causes

A

Testicular damage from:

  • Mumps
  • Undescended testes
  • Trauma
  • Radiotherapy
  • Chemotherapy
  • Cancer

Genetic or congenital disorders that result in defective or absent sperm production, such as:

  • Klinefelter syndrome
  • Y chromosome deletions
  • Sertoli cell-only syndrome
  • Anorchia (absent testes)
31
Q

Male factor infertility causes can be grouped into three broad categories: pre-testicular, testicular and post-testicular causes. State some post-testicular causes

A

Obstruction preventing sperm being ejaculated can be caused by:

  • Damage to the testicle or vas deferens from trauma, surgery or cancer
  • Ejaculatory duct obstruction
  • Retrograde ejaculation
  • Scarring from epididymitis, for example, caused by chlamydia
  • Absence of the vas deferens (may be associated with cystic fibrosis)
  • Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)
32
Q

Following an abnormal semen analysis results, what further investigations may be done in males?

A
  • Ultrasound of testes
  • Hormonal analysis: LH, FSH, testosterone
  • Further imaging e.g. transrectal ultrasound or MRI
  • Vasography: inject contrast into vas deferens and perform x-rays to look for obstruction
  • Testicular biopsy
  • Genetic testing
33
Q

Discuss some management options for male factor infertility

A

Management depends on the underlying cause, and can involve:

  • Surgical sperm retrieval where there is obstruction
  • Surgical correction of an obstruction in the vas deferens
  • Intra-uterine insemination involves separating high-quality sperm, then injecting them into the uterus
  • Intracytoplasmic sperm injection (ICSI) involves injecting sperm directly into the cytoplasm of an egg
  • Donor insemination involves sperm from a donor
34
Q

IVF criteria can vary between different CCGs; discuss the NICE IVF criteria for women:

  • Under 40yrs
  • Aged 40-42yrs
A

Women under 40yrs

Offer 3 cycles of IVF on NHS if:

  • Trying for 2 yrs (regular unprotected sex)
  • Had 12 cycles of artificial insemination with at least 6 of those cycles using intrauterine insemination method

If woman turns 40 during treatment, complete current cycle but don’t offer further cycles.

Women aged 40-42yrs

Offer 1 cycle of IVF on NHS if:

  • Trying for 2 yrs (regular unprotected sex)
  • Had 12 cycles of artificial insemination with at least 6 of those cycles using intrauterine insemination method
  • Never had IVF before
  • No evidence of low ovarian reserve
  • Informed of additional implications/complications of IVF and pregnancy at this age

NOTE FROM NHS WEBSITE

NHS trusts across England and Wales are working to provide the same levels of service. But the provision of IVF treatment varies across the country, and often depends on local CCG policies. CCGs may have additional criteria you need to meet before you can have IVF on the NHS, such as:

  • not having any children already, from both your current and any previous relationships
  • being a healthy weight
  • not smoking
  • falling into a certain age range (for example, some CCGs only fund treatment for women under 35)

Although NICE recommend up to 3 cycles of IVF should be offered on the NHS, some CCGs only offer 1 cycle, or only offer NHS-funded IVF in exceptional circumstances.

35
Q

Each IVF attempt has what % success rate of producing a live birth?

A

25-30%

36
Q

Outline 6 steps involved in IVF

A
  • Supressing the natural menstrual cycle
  • Ovarian stimulation
  • Oocyte collection
  • Insemination/intracytoplasmic sperm injection (ICSI)
  • Embryo culture
  • Embryo transfer
37
Q

Why do we need to supress the natural menstrual cycle during IVF?

A

If we didn’t supress the natural gonadotrophins then ovulation would occur and the follicles that are developing would be released before it is possible to collect them

38
Q

There are two protocols for supressing the natural menstrual cycle & preventing ovulation: GnRH agonists or GnRH antagonists (which is used depends on individual factors). For the GnRH agonist method, discuss:

  • What it involves
  • How it works
A
  • Injection of GnRH agonist (e.g. goserelin) in the luteal phase of menstrual cycle around 7 days before expected onset of menstrual cycle (so in 28 day cycle given on day 21).
  • Initially stimulates pituitary causing LH and FSH surge, however after initial surge there is negative feedback on hypothalamus causing natural production of GnRH to be supressed and this consequently supresses menstrual cycle
39
Q

There are two protocols for supressing the natural menstrual cycle & preventing ovulation: GnRH agonists or GnRH antagonists (which is used depends on individual factors). For the GnRH antagonist method, discuss:

  • What it involves
  • How it works
A
  • Daily SC injections of GnRH antagonists (e.g. cetrorelix) starting from day 5-6 of ovarian stimulation
  • Prevents GnRH stimulating FSH and LH release and hence prevents LH surge and hence ovulation
40
Q

For ovarian stimulation, discuss:

  • Purpose is
  • What it involves
  • What is given when enough follicles have developed
A
  • Promote development of multiple follicles in ovaries (you want to supress natural menstrual cycle so that ovulation doesn’t occur but still need follicles to develop ready for collection)
  • Give SC injections of FSH, starting at beginning of menstrual cycle (usually day 2), for 10-14 days. FSH causes follicles to development. Monitor development of follicles with regular transvaginal ultrasound scans.
  • When enough follicles developed (usually around 18mm) FSH is stopped and hCG injection is given. The hCG injection- sometimes called the “trigger injection”- is given ~36hrs before oocyte collection; works similarly to LH- stimulates the final maturation of the follicles.
41
Q

Discuss what is involved in oocyte collection stage of IVF

A
  • Pt is usually sedated (but not GA)
  • Done under guidance of transvaginal ultrasound
  • Insert needle through vaginal wall into each ovary & aspirate fluid from each follicle (this fluid contains the mature oocytes from the follicles)
  • Fluid is examined under microscope for oocytes
42
Q

Discuss what is involved in oocyte insemination stage of IVF

A
  • Male provides semen sample around time of oocyte collection (alternatively frozen sperm from earlier samples can be used)
  • Mix sperm & egg in culture medium
43
Q

Why do thousands of sperm need to be combined with each oocyte during oocyte insemination stage?

A

Need thousands of sperm to ensure enough enzymes (e.g. hyaluronic acid) is produced to allow one sperm to penetrate the corona radiata & zona pellucida to fertilise the egg

44
Q

If there is male factor infertility, what method may be used for oocyte insemination?

A
  • Intracytoplasmic sperm injection (ICSI) may be used if there are reduced number or quality of sperm
  • Highest quality sperm are isolated from semen sample and injected directly into cytoplasm of egg
45
Q

Discuss what is involved in the embryo culture stage of IVF

A
  • Dishes containing fertilised egg are left in incubator and observed over 2-5 days to see which will develop & grow
  • Monitored until they reach blastocyst stage of development (~ day 5)
46
Q

For the embryo transfer stage of IVF, discuss:

    • When it is done
  • How many embryos transferred
  • How it is done
  • What happens to remaining embryos
A
  • After 2-5 days select high quality embryos
  • Generally a single embryo is transferred however two embryos may be transferred in older women (e.g. >35yrs)
  • Inject embryo into uterus through catheter
  • Remaining embryos can be frozen for future attempts
47
Q

When would someone who has had IVF be advised to do a pregnancy gest?

A

Day 16 after egg collection

*NOTE: positive pregnancy means implantation has occurred; but still possibility of miscarriage or ectopic pregnancy

48
Q

If, after taking pregnancy test, woman is not pregnant what happens next?

A
  • Hormonal treatment stopped
  • Woman then has menstrual period (advise woman this may be heavier than normal)
49
Q

If, after taking pregnancy test, woman is pregnant what happens next?

A
  • Progesterone is given from from time of oocyte collection until 8-10 weeks gestation- usually as vaginal suppositories- to mimic progesterone that would be released by corpus luteum. After 8-10 weeks placenta takes over & don’t need progesterone suppositories
  • Ultrasound scan done at ~7 weeks to check for fetal heartbeat, rule out miscarriage or ectopic pregnancy. After this, if healthy pregnancy, proceed with standard pregnancy care
50
Q

State some potential complications of IVF

A
  • Failure
  • Multiple pregnancy
  • Ectopic pregnancy
  • Ovarian hyperstimulation syndrome
51
Q

State some potential complications related specifically to egg collection

A
  • Pain
  • Bleeding
  • Pelvic infection
  • Damage to bladder or bowel
52
Q

Discuss the pathophysiology of ovarian hyperstimulation syndrome (OHSS)

A
  • OHSS is provoked by the hCG/”trigger” injection given ~36hrs before oocyte collection
  • hCG stimulates release of VEGF from granulosa cells of follicles
  • VEGF increases vascular permeability causing fluid to leak from capillaries
  • Hence, fluid moves from intravascular space to extravascular space resulting in oedema, ascites & hypovolaemia
  • There is also activation of renin-angiotensin system hence you find raised renin levels in pts with OHSS
53
Q

Renin level in OHSS correlates with severity of condition; true or false?

A

True

54
Q

State some risk factors for OHSS

A
  • Younger age
  • Lower BMI
  • Raised anti-Mullerian hormone
  • Higher antral follicle count
  • PCOS
  • Raised oestrogen levels during ovarian stimulation
55
Q

Women are individually assessed for their risk of developing OHSS; discuss what monitoring is done during stimulation with gonadotrophins

A
  • Serum oestrogen (higher= higher risk)
  • Transvaginal ultrasound monitoring of follicles (higher number and larger size= higher risk)
56
Q

In women with higher risk of OHSS, what strategies may be used to reduce risk

A
  • Use GnRH antagonist protocol (as opposed to GnRH agonist protocol)
  • Lower dose of gonadotrophins
  • Lower dose of hCG injection
  • Alternatives to hCG injection (e.g. GnRH agonist or LH)
57
Q

When does early OHSS present?

When does late OHSS present?

A
  • Early: within 7 days of hCG injection
  • Late: from day 10 onwards following hCG injection
58
Q

Describe typical presentation of OHSS

A
  • Abdo pain
  • Abdo bloating
  • Nausea & vomiting
  • Diarrhoea
  • Hypotension
  • Hypovolaemia
  • Ascites
  • Pleural effusions
  • Renal failure
  • Peritonitis from rupturing follicles releasing blood
  • Prothrombotic state (increased risk DVT & PE)
59
Q

Severity of OHSS is based on clinical features; describe features of:

  • Mild
  • Moderate
  • Severe
  • Critical

… OHSS

A
  • Mild: abdo pain & bloating
  • Moderate: nausea & vomiting with ascites on ultrasound
  • Severe: ascites, oliguria, low albumin, high potassium, raised haematocrit (>45%)
  • Critical: tense ascites, anuria, thromboembolism, ARDS

**Highlighted what makes each different/progress to next stage

60
Q

Discuss the management of OHSS

A

Management is supportive with treatment of complications, Mild to moderate can be managed as outpatient. Severe requires admission & critical may require ICU.

  • Oral fluids
  • Monitoring of urine output
  • Monitoring of haematocrit
  • LMWH
  • Ascitic fluid removal via paracentesis if required
  • IV colloids (e.g. human albumin solution)
61
Q

Renin level in OHSS correlates with severity of condition; true or false?

A

Yr4: Obstetrics & Gynaecology (24 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions