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Obstetrics & Gynaecology > Infertility > Flashcards

Infertility Flashcards

1
Q

what percentage of couples will conceive within a year or regular unprotected sex

A

85%

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2
Q

when should investigation and referral for infertility be made?

A

when a couple has been trying to conceive without success for 12 months

6 months if woman is >35 as ovarian stores will be reduced

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3
Q

what are the broad categories of causes of infertility?

A

sperm problems
ovulation problems
tubal problems
uterine problems
unexplained

40% couples have a mix

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4
Q

what general advice should be given to couples trying to get pregnant?

A
  • start taking folic acid 400mcg daily
  • healthy BMI
  • avoid smoking and drinking excessive alcohol
  • reduce stress - affects libido and relationship
  • intercourse every 2-3 days
  • avoid timing intercourse - as can lead to increased stress and pressure in the relationship
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5
Q

what initial investigations can be performed in primary care for someone struggling with fertility

A
  • BMI
  • chlamydia screening
  • semen analysis
  • female hormonal testing
  • rubella immunity in mother
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6
Q

what female hormones can be tested in primary care

A

serum LH and FSH on day 2-5 of the cycle

serum progesterone on day 21 (7 days before end of cycle if not 28 day cycle) of the cycle

anti-mullerian hormone

TFTs when symptoms suggest

Prolactin when symptoms of galactorrhea or amenorrhoea

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7
Q

what does high FSH suggest

A

poor ovarian reserve - the pituitary gland if producing extra FSH in an attempt to stimulate follicular development

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8
Q

what does high LH suggest

A

PCOS

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9
Q

what does a rise in progesterone on day 21 indicate?

A

ovulation has occurred and corpus luteum has formed and started to secrete progesterone

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10
Q

what does a high level of anti-mullerina hormone indicate?

A

good ovarian reserve - most accurate marker of ovarian reserve

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11
Q

what investigations can be performed in secondary care for infertility?

A

ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus

hysterosalpingogram to look at patency of the tubes

laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis

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12
Q

what is a hysterosalpingogram?

A

scan used to assess the shape of the uterus and the patency of the fallopian tubes

tubal cannulation can be performed to open up the tubes

small tube inserted into cervix and an contrast medium is injected into the uterune cavity and fallopian tubes. x ray images taken which give an outline of the uterus and the tubes - seen on x ray and suggest tubal obstruction

infection risk - screen for chlamydia and gonorrhoea before and prophylactic antibiotics often given

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13
Q

what is a laparoscopy and dye test?

A

laparoscopy - dye injected into the uterus and should be seen entering the fallopian tubes and spilling out at the end - not seen if there is an obstruction

can also assess for endometriosis and adhesions and treat these

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14
Q

what are some management options for anovulation?

A
  • Weight loss - can restore ovulation in PCOS
  • Clomifene - stimulate ovulation
  • Letrozole - stimulate ovulation
  • Gonadotropins to stimulate ovulation in women resistant to clomifene
  • Ovarian drilling - used in PCOS
  • Metformin - when there is insulin insensitivity and obesity usually associated with PCOS
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15
Q

What is Clomifene?

A

anti-oestrogen (selective oestrogen receptor modulator)

given on days 2 to 6 of the menstrual cycle to stop negative feedback of oestrogen on the hypothalamus resulting in greater release of GnRH and subsequently FSH and LH

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16
Q

What is ovarian drilling?

A

laparoscopic surgery where the ovaries are punctured to make multiple holes in the ovaries using diathermy or laser therapy

improves hormonal profile resulting in regular ovulation and fertility

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17
Q

what are the options for a women with tubal problems?

A

tubal cannulation during a hysterosalpingogram

laparoscopy to remove adhesions or endometriosis

IVF

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18
Q

how can uterine factors be managed?

A

surgery to correct polyps, fibroids, adhesions or structural abnormalities affecting fertility

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19
Q

how can problems with sperm be managed?

A
  • surgical sperm retrieval
  • surgical correction
  • intra-uterine insemination
  • intracytoplasmic sperm injection
  • donor sperm
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20
Q

What is surgical sperm retrieval and when is it used?

A

used when there is blockage somewhere along the vas deferens preventing sperm from reaching the ejaculated semen

needle and syringe used to collect directly from the epididymis

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21
Q

what is intrauterine insemination?

A

collecting and separating out high quality sperm then injecting them directly into the uterus to give best chance of success

used for same sex couples, HIV and practical issues with vaginal sex

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22
Q

what is intracytoplasmic sperm injection

A

injecting sperm directly into the cytoplasm of an egg

fertilised eggs become embryos and are injected into the uterus of the woman

useful when there are significant motility issues, v low sperm count of other issues with sperm

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23
Q

what is donor insemination

A

sperm from a donor

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24
Q

what does semen analysis examine?

A

quantity and quality of sperm

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25
Q

what instructions should a man be given when giving 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
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26
Q

what are some lifestyle factors that may affect the results and quality of semen analysis?

A
  • hot baths
  • tight underwear
  • smoking
  • alcohol
  • raised BMI
  • caffeine
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27
Q

when is a repeat semen sample indicated?

A

after 3 months in borderline

2-4 weeks with very abnormal results

28
Q

what are normal semen analysis results?

A
  • Semen volume (more than 1.5ml)
  • Semen pH (greater than 7.2)
  • Concentration of sperm (more than 15 million per ml)
  • Total number of sperm (more than 39 million per sample)
  • Motility of sperm (more than 40% of sperm are mobile)
  • Vitality of sperm (more than 58% of sperm are active)
  • Percentage of normal sperm (more than 4%)
29
Q

what is polyspermia?

A

high number of sperm in the semen sample

more than 250 million per ml

30
Q

what is normospermia?

A

refers to normal characteristics of sperm in the semen sample

31
Q

what is oligospermia?

A

reduced number of sperm in the semen sample

mild 10-15 million per ml

mod 5-10 million per ml

severe less than 5 million per ml

32
Q

what is cryptozoospermia?

A

very few sperm in semen sample - less than 1 million per ml

33
Q

what is azoospermia?

A

absence of sperm in the semen

34
Q

what are some pre-testicular causes of infertility?

A

testosterone needed for sperm creation

hypothalamo-pituitary-gonadal axis controls testosterone

hypogonadotrophic hypogonadism (low LH and FSH = low testosterone) due to

pathology of pituitary gland or hypothalamus, suppression due to stress, chronic conditions or hyperprolactinaemia, kallerman syndrome

35
Q

what are some testicular causes of infertility?

A

damage from: mumps, undescended testes, trauma, radiotherapy, chemotherapy, cancer

genetic or congenital disorders such as: Klinefelter syndrome, Y chromosome deletions, sertoli cell-only sundrome, anorchia

36
Q

what are some post-testicular causes?

A
  • 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)
37
Q

what investigations are done to investigate abnormal semen results?

A
  • ref to urologist
  • hormonal analysis with LH, FSH and testosterone levels
  • genetic testing
  • further imaging - transrectal uss or MRI
  • vasography - injecting contrast into the vas deferens and performing x ray to assess for obstruction
  • testicular biopsy
38
Q

what are some management options for male factor infertility?

A
  • 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 dono
39
Q

what is IVF? what is the success rate?

A

In vitro fertilisations

fertilising an egg with sperm in a lab then injecting the resulting embryo into the uterus

25-30% success rate

40
Q

what does a cycle of ivf involve?

A

single episode of ovarian stimulation and collection of oocytes - single cycle may produce several embryos

each embryo can be transferred separately in multiple attempts at pregnancy all during 1 cycle

embryos can be frozen and used at a later date

41
Q

outline the steps involved in the IVF process

A

suppressing the natural menstrual cycle

ovarian stimulation

oocyte collection

insemination

embryo culture

embryo transfer

42
Q

what are the 2 options for suppressing the natural menstrual cycle?

A

GnRH agonists

GnRH antagonists

choice depends on individual factors

43
Q

describe the GnRH agonist protocol

A

injection of GnRH agonist given in the luteal phase of the menstrual cycle (around 7 days before expected onset of menstruation)

stimulates pituitary gland to secrete large amount of FSH and LH

after initial surge there is negative feedback on hypothalamus and therefore production of GnRH is suppressed

44
Q

describe the GnRH antagonist protocol?

A

daily SC injections of GnRH antagonist starting from days 5/6 of ovarian stimulation

suppresses body releasing LH and causing ovulation to occur

45
Q

name an example of a GnRH agonist and a GnRH antagonist

A

agonist = goserelin

antagonist = cetrorelix

46
Q

describe how ovarian stimulation is carried out?

A

medication to promote the development of multiple follicles in the ovaries

starts at the beginning of the menstrual cycle with SC injections of FSH over 10-14 days

FSH stimulates development of follicles and monitored with regular transvaginal USS

when enough have developed to adequate size, FSH stopped and hCG injection given 36 hours before collection

it naturally stimulates the final maturation of the follicles, ready for collection - known as trigger injection

47
Q

describe the oocyte collection stage

A

collected from ovaries under guidance of transvaginal uss

needle inserted through vaginal wall to each ovary to aspirate fluid from each follicle

fluid contains mature oocytes from the follicles

performed under sedation

fluid examined for oocytes

48
Q

describe the oocyte insemination step

A

male produces semen sample around time of oocyte collection (of frozen used from earlier sample)

mixed in a culture medium

1000s needed to combine with each oocyte to produce enough enzyme for 1 sperm to penetrate the corona radiata and zone pellucida

49
Q

describe the embryo culture stage of IVF

A

left in incubator and observed over 2-5 days to see which will develop and grow

monitored until they reach blastocyst stage

50
Q

describe embryo transfer stage

A

after 2-5 days the highest quality embryos are selected for transfer

catheter inserted under uss guidance through cervix into uterus

single embryo injected through catheter into uterus and catheter is removed

normally only 1 is transferred but sometimes 2 in older women

remaining frozen

51
Q

when is a pregnancy test performed?

A

pregnancy test is performed around day 16 after egg collection:

+ve = implantation has occurred

-ve = implantation has failed so hormonal treatment is stopped, woman will have a period which may be heavier than normal

52
Q

why is progesterone given and for how long for?

A

used from time of oocyte collection until 8-10 weeks gestation, usually in the from of vaginal suppositories

mimics progesterone that would have been released by corpus luteum

from 8-10 weeks placenta takes over production of progesterone

53
Q

when is an uss performed

A

early in pregnancy - around 7 weeks to check for fetal heartbeat, rule out miscarriage or ectopic pregnancy

when uss conforms healthy pregnancy, remainder of pregnancy can proceed with standard care

54
Q

what are the main complications relating to the overall process?

A

failure

multiple pregnancy

ectopic pregnancy

OHS

55
Q

what are some risks associated with egg collection?

A

pain

bleeding

infection

damage to bladder or bowel

56
Q

what is ovarian hyperstimulation syndrome?

A

complication of ovarian stimulation during IVF infertility treatment

associated with use of hCG to mature follicles during final steps of ovarian stimulation

57
Q

what is the pathophysiology of OHSS?

A

increase in vascular endothelial growth factor released by granulosa cells of the follicles

VEGF increases vascular permeability causing fluid to leak from capillaries - fluid moves from intravascular space to the extravascular space

causes oedema, ascites, hypovolaemia

provoked by trigger injection

57
Q

what is the pathophysiology of OHSS?

A

increase in vascular endothelial growth factor released by granulosa cells of the follicles

VEGF increases vascular permeability causing fluid to leak from capillaries - fluid moves from intravascular space to the extravascular space

causes oedema, ascites, hypovolaemia

provoked by trigger injection

58
Q

risk factors for OHSS

A
  • Younger age
  • Lower BMI
  • Raised anti-Müllerian hormone
  • Higher antral follicle count
  • Polycystic ovarian syndrome
  • Raised oestrogen levels during ovarian stimulation
59
Q

how is OHSS prevented?

A

during stimulation they are monitored with serum oestrogen (higher level = higher risk) levels and uss monitoring (larger size and number = higher risk

60
Q

what can be done to reduce risk on OHSS in higher risk women?

A
  • Use of the GnRH antagonist protocol (rather than the GnRH agonist protocol)
  • Lower doses of gonadotrophins
  • Lower dose of the hCG injection
  • Alternatives to the hCG injection (i.e. a GnRH agonist or LH)
61
Q

what are the features of OHSS

A
  • Abdominal pain and bloating
  • N&V
  • Diarrhoea
  • Hypotension
  • Hypovolaemia
  • Ascites
  • Pleural effusions
  • Renal Failure
  • Peritonitis from rupturing follicles releasing blood
  • Prothrombotic state
62
Q

OHSS is classified depending on severity, how?

A
  • Mild: Abdominal pain and bloating
  • Moderate: Nausea and vomiting with ascites seen on ultrasound
  • Severe: Ascites, low urine output (oliguria), low serum albumin, high potassium and raised haematocrit (>45%)
  • Critical: Tense ascites, no urine output (anuria), thromboembolism and acute respiratory distress syndrome (ARDS)
63
Q

how is OHSS managed?

A

supportive treatment: oral fluids, monitoring urine output, LMWH, ascitic fluid removal, IV colloids

mild-moderate can be managed as outpatient

severe require admission and critical cases may require ITU admission

64
Q

what is the significance of raised haematocrit?

A

monitored to assess the volume of fluid in the intravascular space

as haematocrit goes up - indicates less fluid in intravascular space = dehydration

Obstetrics & Gynaecology (50 decks)

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