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Y3 - Repro > Infertility > Flashcards

Infertility Flashcards

1
Q

What is the definition of infertility?

A

Failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse in the absence of known reason in a couple who have never conceived a child

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2
Q

What are the types of infertility?

A

Primary - couple has never conceived

Secondary - couple has had a previous pregnancy, including those that did not result in live birth

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3
Q

What factors increase the chance of conception?

A

Young paternal age
Healthy BMI
Non-smoker
Timing intercourse with ovulation

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4
Q

What blood tests are done to test for causes of infertility?

A 
FSH and LH
Oestadiol
Mid-cycle progesterone on day 21 (7 days before end of cycle)
TFT
Infection screen - rubella, HIV, hepatitis B/C
Prolactin
testosterone
Sex hormone binding globulin
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5
Q

What is a progesterone challenge test?

A

Progesterone is given, a bleed after a 5 day course confirms oestrogen levels are normal

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6
Q

What factors are assessed in a semi analysis?

A 
Volume 
pH
Density and concentration of sperm
Motility
Sperm progression and morphology
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7
Q

What are causes of male factor infertility?

A 
Idiopathic
Cystic fibrosis
Vasectomy
Congenital - cryptorchidism, chromosomal abnormalities
Infections - mumps, STIS
Endocrine causes
Testicular tumours
Sperm abnormalities
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8
Q

Why does cystic fibrosis cause infertility in males

A

CF causes obstruction or absence of the vas deferent bilaterally (congenital bilateral absence of vas deferens - CBAVD)

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9
Q

What are the blood results in obstructive causes of infertility in males?

A

Normal LH, FSH and testosterone

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10
Q

What is cryptorchidism?

A

One or both testes are undescended into the dependent part of the scrotal sac

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11
Q

What is the presentation of cryporchidism?

A

Testes cannot be palpated within the dependent part of the scrotal sac
May be found in the upper part of the scrotum, the inguinal canal, intra-abdominally or none of these places

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12
Q

Who is cryptorchism more common in?

A

Premature babies

Babies with low birth weigher or small for gestational age

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13
Q

What is Kleinefelter’s syndrome?

A

47 XXY

Genetical male with an extra X chromosome

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14
Q

What is the presentation of Kleinefelter’s syndrome?

A 
Slight developmental delay
Reduced facial fair
Poor muscle tone
Gynaecomastia at puberty
Small firm testes
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15
Q

What do blood tests show in Kleinefelter’s syndrome?

A

High GnRH

Low testosterone

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16
Q

How is Kleinefelter’s syndrome diagnosed?

A

Karyotype

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17
Q

How can mumps cause infertility?

A

Mumps orchitis can cause reduced spermatogenesis and can cause obstructive infertility
Testicular swelling can damage seminiferous tubules and affect sperm production

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18
Q

What is the prognosis of infertility caused by mumps?

A

Shot-term - improves in the months after recovery

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19
Q

Which endocrine tumours can cause infertility?

A 
Pituitary tumours
Hypothalamous disorders
Hypo and  hyperthyroidism
Diabetes
Congenital adrenal hyperplasia
Steroids abuse
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20
Q

What do blood tests show in pituitary and hypothalamus causes of infertility?

A

Low LH, FSH and testosterone

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21
Q

Why can both hypo and hyperthyroidism cause reduced fertility?

A

Hyper - decreased sexual function

Hypo - increased prolactin

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22
Q

How does congenital adrenal hyperplasia cause infertility in men?

A

Increased testosterone

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23
Q

What is globozoospermia?

A

Sperm abnormality where spermatozoa have rounded heads instead of oval, and no acrosome
Without this the sperm can’t fuse with the egg

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24
Q

What are the categories of female infertility?

A

Anovulatory infertility

Tubal factor infertility

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25
Q

What are hypothalamic causes of anovulatory infertility?

A

Anorexia, bulilia
Excess exercise
Idiopathic hypogonadotrophic hypogonadism
Kallman syndrome

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26
Q

What do blood tests show in anorexia, bulimia or excess exercise causing anovulatory infertility?

A

Low FSH and LH

Low oestradiol

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27
Q

What is idiopathic hypogonadotrophic hypogonadism?

A

Incomplete or absent puberty

Lack of GnRH production by the hypothalamus

28
Q

What do blood tests show in idiopathic hypogonadotrophic hypogonadism?

A

Low FSH and LH
Low oestrogen
Negative progesterone test

29
Q

What is Kallman syndrome?

A

Hypogonadotrophic hypogonadism causing incomplete or absent puberty and anosmia

30
Q

How does hyperprolactinaemia cause anovulatory infertility?

A

Increased level of prolactin prevents ovulation

31
Q

What are the clinical features of hyperprolactinaemia?

A

Amenorrhoea or oligomenorrhea

Galactorrhoea

32
Q

What are causes of hyperprolactinaemia?

A

Prolactinoma

Dopamine antagonist drugs

33
Q

What investigations are done for hyperprolactinaemia?

A

Pituitary function tests
MRI pituitary
Medication review

34
Q

What is the management of hyperprolactinaemia?

A

Dopamine agonists: bromocriptine, cabergoline

Surgery to remove tumour

35
Q

What is Sheehan’s syndrome?

A

Post-partum hypopituitarism

Can cause anovulation

36
Q

How does PCOS cause infertility?

A

Overproduction of oestrogen means those with the condition do not release an ovum
In the long term the increased levels of testosterone can impair ovum quality

37
Q

What do blood tests show in PCOS?

A

High LH
High free androgens
Impaired glucose tolerance

38
Q

What is the management of infertility in PCOS?

A

Clomiphene +/- metformin
Ovarian diathermy and gonadotrophin induction
IVF

39
Q

How does clomiphene work?

A

An anti-oestrogen

Helps to induce ovulation by increasing release of FSH/LH so first line for women trying to conceive

40
Q

What is premature ovarian failure?

A

Ovaries stop producing oestrogen and healthy ova before age 40

41
Q

What are causes of premature ovarian failure?

A

Idiopathic
Genetic disorders - Turner’s, fragile X
Chemotherapy or radiotherapy
Autoimmune response to ovarian tissue

42
Q

What are symptoms of premature ovarian failure?

A 
Hot flushes
Night sweats
Atrophic vaginitis
Oligomenorrhea or amenorrrhoea
Anovulation - infertility
43
Q

What do investigations show in premature ovarian failure?

A

High FSH and LH

Low oestradiol

44
Q

What is the management of premature ovarian failure?

A

HRI

45
Q

How can tubal factors cause infertility?

A

A blockage can occur in one or both of the fallopian tubes, preventing the sperm from arching the ovum
Complete blockage or tubal scarring causing narrowing

46
Q

What are infective causes of tubal factor infertility?

A

Pelvic inflammatory disease
Trans-peritoneal spread from e.g. appendicitis
Iatrogenic source of infection - eg. IUD, hysteroscopy

47
Q

What are non-infective causes of tubal factor infertility?

A

Endometriosis
Salpingitis isthmica nodosa
Uterine polyps
Uterine fibroids

48
Q

What is the management of endometriosis causing infertility?

A

Laparoscopic surgery ro remove endometrial growth, cysts and adhesions without damaging female reproductive organs

49
Q

What is salpingitis isthmica nodes?

A

Nodular scarring of the fallopian tube due to inflammation
Development of irregular benign extensions of the tubal epithelium
Results in narrowing of tube

50
Q

How can polyps cause infertility?

A

Can develop at the opening of the fallopian tubes, blocking them and preventing sperm reaching the ovum
Polyps that develop in the endometrium can interfere with the process of implantation

51
Q

What are the options for assisted conception treatment?

A

Donor insemination
Intra-uterine insemination
In vitro fertilisation
Intra-cytoplasmic sperm injections

52
Q

What are the indications for assisted conception treatment?

A

Couples with fertility issues where at least one partner does not have a biological child
Same sex couples
Preservation of fertility in patients undergoing cancer treatment or gender reassignment where fertility may be lost
To avoid transmission of BBV e.g. HIV
To allow pre-implantation diagnosis of certain inherited disorders

53
Q

What are the criteria for assisted conception treatment?

A

Couple co-habiting in a stable relationship for minimum 2 years
Both parents non-smoking, no illegal substances, methadone free, no alcohol
BMI of female above 18.5 and below 30
Neither partner ever had sterilisation
Female up to date with smears, immunised against rubella and screens for BBVs

54
Q

What is intra-uterine insemination?

A

Direct placement of the sperm inside the uterus

55
Q

When is intra-uterine insemination possible?

A

Where sperm and semen are healthy, ovulation is taking place and there is no tubal disease

56
Q

What are indications for intra-uterine insemination?

A

Sexual dysfunction
- Ejaculation disorders, erectile dysfunction, sexual pain disorders
Female same sex relationships - using donor sperm
Male same sex relationships - using surrogacy

57
Q

What is the process of IVF?

A
  1. Down regulation - GnRH analogues to shut down natural menstrual cycle
  2. Ovarian stimulation - ovarian follicular development and oocyte maturation by gonadotrophin hormone injections, endometrial wall thickens
  3. Oocyte collection - un theatre under USS guidance, needle inserted trans-vaginally to collect oocytes
  4. Fertilisation - sperm placed in petri dish with oocyte where fertilisation takes place and zygote forms
58
Q

What is the process of intra-cyclic sperm injection?

A
  1. Down regulation - GnRH analogues to shut down natural menstrual cycle
  2. Ovarian stimulation - ovarian follicular development and oocyte maturation by gonadotrophin hormone injections, endometrial wall thickens
  3. Oocyte collection - un theatre under USS guidance, needle inserted trans-vaginally to collect oocytes
  4. Fertilisation - one sperm immobilised and injected into the cytoplasm of the oocyte
59
Q

When is intra-cyclic sperm injection preferred?

A

Low numbers of sperm
Reduced sperm motility
Abnormal sperm morphology

60
Q

What are the indications for intra-cyclic sperm injection?

A

Severe male factor infertility
Previous failed fertilisation with IVF
Pre-implantation genetic diagnosis

61
Q

What are the complications of assisted reproductive treatment?

A 
Ovarian hyper-stimulation syndrome
Multiple pregnancy
Ectopic pregnancy
Increased risk of miscarriage
Surgical risk in oocyte collection
62
Q

What is ovarian hyper-stimulation syndrome?

A

In response to ovarian stimulation in stage 2 of IVF and ICSI
Large numbers of growing follicles and high oestradiol can lead to release of inflammatory markers and vasoactive substances
This can cause fluid shift from blood vessels to third compartment and fluid buildup in the abdomen
If severe -thromboembolic disease and acute respiratory distress syndrome

63
Q

What is the presentation of ovarian hyper-stimulation syndrome?

A

Bloating
Abdominal distension
Nausea and vomiting
In woman undergoing IVF

64
Q

What is the management of ovarian hyper-stimulation syndrome before embryo transfer?

A

Elective freeze

Single embryo transfer

65
Q

What is the management of ovarian hyper-stimulation syndrome after embryo transfer?

A

Monitor with USS and blood tests
Reduce thrombosis risk (fluids, TED stockings, frogmen)
Analgesia

Y3 - Repro (13 decks)

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