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GYNE CLERKSHIP > INFERTILITY > Flashcards

INFERTILITY Flashcards

1
Q

STANDARD INFERTILITY EVALUATION (ASRM, 2006)

A

Semen Analysis
Assessment of Ovulation
Hysterosalphingogram - make sure patient is not pregnant; avoid exposure of eggs to radiation

If indicated:
Ovarian reserve
Laparoscopy

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2
Q

Always dapat may pake sa male partner

Ask if:

A

fathered any childen before?
erectile dysfunction?
DM?

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3
Q

Pertinent data na need sa Past Medical History

Give 5

A 
PCOS (anovulation)
Endometriosis (tubal obstruction)
PID (tubal obstruction)
STD
Appendectomy (previous surgeries) --> Adhesions
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4
Q

residence of the couple, do they live together?

A

less time to have sex if magkalayo

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5
Q

If anovulation ang problem why cannot conceive, what conditions would you think of and what workups?

A

PCOS - high LH, FSH ratio leading to anovulatory cycles

Hypothyroidism - thyrotropin releasing hormone –> stimulation of prolactin

Hyperprolactinemia -
High prolactin levels inhibit secretion of FSH, which is the hormone that triggers ovulation. So, if your prolactin levels are high, your ovulation may be suppressed.

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6
Q

Serum Prolactin level normal values

A

Nonpregnant women: less than 25 ng/mL (25 µg/L)

Pregnant women: 80 to 400 ng/mL (80 to 400 µg/L)

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7
Q

TSH, T3, T4 levels normal values

A

TSH normal values are 4.5 to 5.0 mU/L.

Serum TSH normal – No further testing performed

  • Serum TSH high – Free T4 added to determine the degree of hypothyroidism
  • Serum TSH low – Free T4 and T3 added to determine the degree of hyperthyroidism

FT4 is between 10-28 pmol/l.

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8
Q

dx and

treatment for PROLACTINOMA

A

dx: Serum PRL (280)
Cranial MRI scan - if there is macro or microadenoma (10mm cut off)

Prescription
Bromocriptine (Parlodel) 2.5mg/tablet
Sig: Take 1 tablet orally
2 weeks? Reassess
If symptoms improve - continue for 4 weeks
May be given for as long as 6 months

Medroxyprogesterone acetate (Provera) 10mg/tab (10 TABLETS)
Sig. Take 1 tablet orally at night
Wait for bleeding as soon as 3 days up to 7 days after last tab
After she bleeds - count that as day 1 - tell her to take it again day 16-25 (continue for 6 cycles)

After 1 month can check again with prolactin levels because ovulation may revert back to normal

Follow up
Reassess Serum Prolactin after 6 months
If responsive to MPA, may continue treating Prolactinoma

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9
Q

enlargement of thyroid gland grading

GRADING (0, Ia, Ib, II, III)

A

GRADING (0, Ia, Ib, II, III)

0 - no goiter
Ia - Goiter detectable only by palpation & not visible when neck is fully extended
Ib - Goiter visible with neck extension
II - Goiter visible even if neck not extended, as in kahit kausap mo siya nakikita mo
III - very large goiter recognized at a distance, nasa kabilang classroom kita mo

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10
Q

progesterone withdrawal test

A 
(+) Bleed: amenorrhea dt anovulation (PCOS, hyperthyroidism, hyperprolactinemia)
(-) Bleed: prob with estrogen secretion
Give estrogen and prog
(+) bleed: HPO axis defect
(-) bleed: uterine defect
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11
Q

Only diagnostic workup for the male

what do you evaluate doon?

A

SEMEN ANALYSIS - eliminate male factor first since it is inexpensive and easier to do

Abstinence for 2-3 days for adequate spcimen
perform act of coitus (catholics) not masturbation
POST COITAL TEST: specimen collected at endocervical area after the couple have sex

  • morphology
  • motility
  • liquefaction time - some ejaculate are too thick loaded with mucin sperm cannot easily reach ovum

after this work up the woman

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12
Q

How do you evaluate Ovulation?

A
  1. Ultrasound of Follicles - may suffice to check for ovulation

Evaluate growth of follices at day 12
dominant follicle - up to 20 mm or 2 cm
mature follicle - 18 mm

Day 16, the dominant follicle should’ve ruptured and shrink = OVULATION

  1. Urinary LH - easier to do; document LH surge to predict ovulation (parang pregnancy test kit)
    Can advise couple to have sex when urinary LH is positive
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13
Q

problems in the fallopian tube like _________ can cause infertility

A

infection –> ascend and affect mucosa of the fallopian tube –> ADHESION (answer)

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14
Q

fallopian tube function in fertility

A

tubes wont be able to pick up the extruded oocyte and the sperm cannot reach the fallopian tube

tubes SUCTION the dominant follicle to the ampulla where it waits for fertilization

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15
Q

past history of ________

A

ruptured appendicitis

previous appendectomy

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16
Q

How would you evaluate patency of Fallopian Tubes

2 procedures
When is it done?

Precaution

A

HYSTEROSALPHINGOGRAPHY - outpatient procedure, anesthesia no need for anesthesia; XRAY method dye will be injected into the genital tract

Normal or Patent tubes - spillage of dye seen in xray
Abnormal: dilatation without spillage

Day 8-10 - we have to wait for mens to avoid irradiation and possible pregnancy

Make sure patient is not pregnant

17
Q

Prophylactic Antibiotic for Hysterosalphingography

A

Doxycycline 100 mg BID, for 3 days, starting 1 day before the procedure

18
Q

How would you evaluate patency of Fallopian Tubes
that is both diagnostic and therapeutic

advantage?

A

LAPAROSCOPY with CHROMOPERTUBATION
Methylene blue or sterilized milk

Both diagnostic and therapeutic

Possible intraoperative adhesion in ileocecal area

Endometriosis (fixation, retroverted uterus)

ADHESIOLYSIS - can be performed immediately during the procedure

CYSTECTOMY - if there are cysts

Remove implants if endometriosis present -

19
Q

SURGICAL TREATMENT FOR INFERTILITY

A

Laparoscopy with Adhesiolysis

Salpingostomy - for distal obstruction

20
Q

Ovulatory agents for PCOS

Note: Do progesterone withdrawal test muna

A

MPA - amenorrheic patients
Clomiphene Citrate - not amenorrheic; Clomifene appears to stumulate the release of gonadotropins, follicle-stimulating hormone (FSH), and leuteinizing hormone (LH), which leads to the development and maturation of ovarian follicle, ovulation, and subsequent development and function of the coprus luteum, thus resulting in pregnancy.

Letrozole (more effective) -
Letrozole is a non-steroidal type II aromatase inhibitor. prevents the conversion of androgens to estrogen. This action leads to elevation in LH (off label use but more effective) Letrozole (aromatase inhibitory) let LH win!!!!!!!

21
Q

MOA of letrozole

A

Letrozole (more effective) -
Letrozole is a non-steroidal type II aromatase inhibitor. prevents the conversion of androgens to estrogen. This action leads to elevation in LH (off label use but more effective) Letrozole (aromatase inhibitory) let LH win!!!!!!!

22
Q

MOA of clomiphene citrate (clomid) (clomin) (clostil)

instructions to patient

A

Clomiphene Citrate - not amenorrheic; Clomifene appears to stumulate the release of gonadotropins, follicle-stimulating hormone (FSH), and leuteinizing hormone (LH), which leads to the development and maturation of ovarian follicle, ovulation, and subsequent development and function of the coprus luteum, thus resulting in pregnancy.

Start 50 mg dose given as early as day 2 to day 6 of menstrual cycle (early proliferative phase)

check utz for evidences of ovulation
collapsed and presence of fluid in the cul de sac
presence of corpus luteum

Goal: follicle formation
Schedule intercourse within 24 hours

23
Q

diagnosis if patient is nulligravid

A

PRIMARY INFERTILITY

24
Q

what conditions would you think of when you are considering infertility?

HI YIELD NEVER FORGET kasi ito magguide sa history pe mo

A

Ovulatory causes - pcos, hyperthyroid, prolactinoma

tubal causes - PID, endometriosis, adhesions from previous surgeries

25
Q

On pelvic exam, saan ka magfofocus pag infertility

A

IE

palpate for any tenderness or massess
mobility ng adnexa
if they are fixed - adhesions

26
Q

If older patient, what diagnostics would you request?

A

AMH (anti mullerian hormone) - best test for ovarian reserve; DONE ANY TIME

expected to be low

normal blaue - >1 ng/mL

when levels readh 0.05 ng/mL; menopause occurs within 4 to 5 years

GYNE CLERKSHIP (14 decks)

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