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Obs & Gyn > infertility > Flashcards

infertility Flashcards

1
Q

define infertility

A

inability of heterosexual couples to acheieve a clinical pregnancy within 12 months od beginning regular unprotected sexual intercourse

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2
Q

define primary and secondary infertiliy

A

primary - no previous pregnancies

secondary- at least one previous pregnancy

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3
Q

incidence of infertility in the popoulation

A

1 in 7 couples at some point

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4
Q

in a normal fertile couple what are the percentage changes of getting pregnant after:
1 month
6 months
1 year
2years

A

1 month- 30%

6 months- 60%

1 year- 84%

2 years- 92%

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5
Q

factors affecting fertility 5

A

age
-mostly female issue
-some evidence of male age influence

previous pregnancy

duration of sub-fertility
- if over 3 years chance of conception only 1-3% per cycle

timing of intercourse

weight

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6
Q

how does timing of intercourse affect fertility

A

sperms needs to be deposited BEFORE ovulation
-as progesterone affects cervical mucus

2-3 times a week

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7
Q

how does weight affect fertility

A

less likely if BMI <18.5 or > 30

other weight related pregnancy problems important also
- increased risk of miscarriage
-GDM
-PIH (pregnancy induced hypertension)
-DVT

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8
Q

state the holy triad of reproductive physiology

A

sperm

egg

meet and implant

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9
Q

how can causes of infertility be classified
-percentage chance for each

A

male - 30%

ovulatory - 25%

unexplaiend 25%

tubal 15%

endometrosis 5%

*-often combined

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10
Q

management prinicples of infetility 4

A

both partenrs should be involved throughout

inital health promotion

history, exam, investigations

treatment

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11
Q

health promotion domains for inferility 6

A

smoking

alcohol

recreational drugs

obesity
-takes longer to conceive
-males >30MBI also reduced fertility

low BMIs (<19) with oligo-amenorrhoea

folic acid helps avoid NTDs (neural tube defects)

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12
Q

how does smoking affect fertility 2

A

reduces female ferility (even passive)

reduces male sperm quality

*-refer for smoking cessation

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13
Q

alcohol consumption for males and females trying to conceive

A

female -1-2 units once or twice a week

male - 3-4 units a day is OK (but intoxication affects sperm quality)

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14
Q

which recreational drugs in partiuclar affect infertility

A

esp body building supplkemtns for male s

-decreases sperm activity and takes months to recover

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15
Q

regarding semen analysis
-when is the sample collected

A

after 2-5 days of abstienece

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16
Q

what laboratory factors are used in semen analysis 3

A

concentration

total motility

normal forms

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17
Q

regarding semen analysis
-what is the minimum concentration

A

> 15mill/ml

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18
Q

regarding semen analysis
-what is the minimum total motility

A

> 40%

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19
Q

regarding semen analysis
-what is the minimum normal forms
*-what is included in assessing normal forms

A

≥4%

-count, motiltiy, morphology

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20
Q

other factors assessed in semen analysis 3

A

volume – ≥1.5ml
progressive motility - >32%
vitality – 58%

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21
Q

what can cause an abnormal semen analysis result 3

A

low (or absent) sperm numbers

low motility

poor quality

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22
Q

terminology for semen abnormalities
azoospermia

A

absent sperm

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23
Q

terminology for semen abnormalities
oligospermia

A

very few sperm

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24
Q

terminology for semen abnormalities
asthenospermia

A

very immotile sperm

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25
Q

terminology for semen abnormalities
teratospermia

A

abnormal morphology

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26
Q

how can causes of male subfertility be classified 3

A

defects in:
-sperm transportation
-sperm production
-hypogonadotrophism (rare)

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27
Q

what is assessed in a subfertile male 5

A

seminal analysis

history

testicular examination

FSH

karyotype if severe oligo or azoospermia
-? CF carrier; Y deletions

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28
Q

regarding semen analysis
-when is the sample collected

A

after 2-5 days of abstinence

-analysed in dedicated lab with strict regulations

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29
Q

how can causes of azoospermia be split

A

obstructive

non obstructive

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30
Q

basic pathophys of obstructive azoospermia

A

normal spermatogenesis

inability to leave in ejaculate

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31
Q

causes of obstructive azoospermia 2

A

blockage in epididymis or vas deferens

congenital absence of vas deferens (TEST CF)

32
Q

basic pathophys of non obstrutive azoospermia

A

testicular failure (high FSH)

-small testicular volumes

33
Q

testing for non obstrutive azoospermia

A

biopsy - ?any spermatogenesis

karyotype for ?XXY (klinefelters)

Y microdeltions

34
Q

other than obstrutive and non obsturtive azoospermia what is a third type
-how can it be caused

A

RARE
=failure to stimjalte speramtogensis

=hypogonadotorphic hypogonadism
-low FSH

35
Q

male subfertility management options 2

A

IVF with intracytoplasmic sperm injection (ICSI)
-resuls are better than IVF
-better for obstrutive than non obstructive azoospermia

donor insemination
-if ICSI not feasible eg. if no quality sperm extracted

36
Q

how can female infertility be split

A

ovulatory

tubal

37
Q

when does ovulation occur in the cycle
-what is released

A

day 21
-progesterone

38
Q

regarding women infertility
-define group 1

A

women with primary or secondary amenorrheoea
-low levels of endogenous gonadotorpins
-negilibile endogenous oestrogen activity

39
Q

regarding women infertility
-define group 2

A

anovulatoin associated with a variety of menstural disorders (including amenorrhea)
-exhibit distinct endogenous oestorgen activity whose urinary and serum gonadotropins are in the normal range

40
Q

regarding women infertility
-define group 3

A

primary or seocndary ammenorhea due to primary ovarian failure with low endogenous oestrogen acitivyt and pathologically high gonandotooin levels

41
Q

summaries the groups of infertile women 3

A

1- primary or secondary amenorrhoea
-low gonadotropins, no (v low) oestrogen

2- anovulation due to menstrual disorders
-normalgonadotorpins, normal oestrogen

3-primary or secondary amenorrhea due to primary ovarian failure
- high gonadotropins, low oestrogen

42
Q

regarding hypothalamic pituitraty fialure resulting in infertility in women (group 1)
-what can affect the hypothalamic part 3

A

weight stress exercise

craniopharyngioma

kallmans syndrome

43
Q

regarding hypothalamic pituitraty fialure resulting in infertility in women (group 1)
-what can affect the pituitary part 1

A

adenoma

44
Q

what are the lab findings in gorup 1 infertility in women 4

-what investigation could be useful in this group

A

decreased FSH

decreased LH

decreased E2

normal or increasted PRL (prolactin)

-MRI check for spcare occupying lesion

45
Q

management of group 1 infertile women 2

-medical managemnt 2

A

increase BMI and exercise in moderation

-treat the cause

medical management
-GnRH agonist
-given in pump - pulsatile release- mimic normality
-limited aviablaibly
-advantages include mono-ovulation and increased live birth success

;gonadotropins (FSH/LH)
-problems with ovairna hyperstimulation
-multiple ovulation
-multiple pregnancy

46
Q

cuases of group 2 (hypothalamic-pituitary dysfunction) infertility in women 5

A

85% anovulatory suibferitlity
-mainly PCOS/PCO

others:
-hyperprolactinaemia
-hypothyroid
-hyperthyroid
-adrenal insufficiency

47
Q

how is hyeprporlactinaemia treated as a cuase of infertility

A

dopamine agnoist
-cabergoline or bromocriptine

48
Q

hormoen levels in PCOS (group 2 inferiltity) 4

A

Normally this ratio is about 1:1 – meaning the FSH and LH levels in the blood are similar. FSH and LH are often both in the range of about 4-8 in young fertile women. In women with polycystic ovaries the LH to FSH ratio is often higher – for example 2:1, or even 3:1

E2 normal

prolactin normal

free andogen index (FAI) increased

49
Q

what is the most common form of anovulatory infertiltiy

A

polycycstic ovarian syndrome (PCOS)

50
Q

prevalence of PCOS

A

20% of woemn

51
Q

what criteria is used for PCOS diagnosis
-how many elements of this criteria are need for diagnosis

A

rotterdam criteria

  • 2 of 3
52
Q

state the cirteria for PCOS diagnosis (rotterdam criteria) 3

A

clinical or biochemical evidence

oligomenorrhoea/amenorrhoea

ultrasound feature of PCO

53
Q

state the cirteria for PCOS diagnosis (rotterdam criteria) 3

A

clinical or biochemical evidence

oligomenorrhoea/amenorrhoea

ultrasound feature of PCOS

54
Q

what is the ultrasound finding in PCOS

A

string of pearls

55
Q

how does PCOS affect feritltiy

A

ovulatory function

oocyte quality

endometrial receptivity

*? secondary to obestiy, metabolic and inflammatory distrubance s

56
Q

mainstay of PCOS managemtn

A

weight loss

-even if normal BMI - 10% weight loss- increased ovulation to approx 80%

57
Q

define ovarian drilling as a treatment for PCOS infertility

A

Ovarian drilling involves laparoscopic surgery. The surgeon punctures multiple holes in the ovaries using diathermy or laser therapy. This can improve the woman’s hormonal profile and result in regular ovulation and fertility.

-as effective as GnRH for PCOS
-80% ovulation
-14% miscarraige
-use after failed medical management

58
Q

first line medical PCOS fertiltiy managemnt

A

letrozole

59
Q

MOA of letrozole for PCOS infertilityh

A

armoatase inhibitor
-block ostreogen biosynthesis -> blocks negative feedback -> increased FHS-> ovulation stimulation

60
Q

previous first line PCOS feritlity medical mangemtn

A

clomiphene

61
Q

MOA of clomiphene for PCOS feritlity

A

SERM
-selective oestrogen receptor modulator
-blocjs E2 receptor at pituitary
blocks negfative geedback-> increased fSH-> ovulation stimulation

62
Q

why is letrozole preferred over clomiphene for fertiltiyu management 4

A

increased ovulation and pregnancy rates

has a decreased risk of multiple preganncy

decreased risk of ovarian cancer

decreased risk of ovarian hyperstimulation

63
Q

when is IVF used in PCOS feritliy managemnt

A

stimulation after GnRH analoauge down reulafion of pituitary with FSH injections to stimulate ovulation

64
Q

define ovarina hyperstimulatoin

A

ovaries over respond to gonadotrophin injfections

-ssytemic diseas resulting from release of vasoactive products from hyperstimulated ovaries

1% risk but 5% risk in PCOS

65
Q

severe manifestiaatiosn of ovarian hyeprsitmulation 4

A

thrombosis

renal dysfunction

liver dysfunction

adult respiratory distress syndrome

66
Q

lab findings in group 3 (ovarian fialure/ insuffiences) infertility in women 2

A

increased FHS
decreased E2

67
Q

lab findings in group 3 (ovarian fialure/ insuffiences) infertility in women 2

A

cuaincreased FHS
decreased E2

68
Q

causes of group 3 (ovarian fialure/insuffifences) inferitlity in women 9

A

Idiopatihic
Chemo/XRT
Surgical removal of ovaries
Autoimmune
Chromosomal
Turners (45XO)/ Turners mosaic
Pure gonadal dysgenesis
Androgen insensitivity (46XY)
Fragile X

69
Q

most common group 3 (ovarian fialure/insuffieincey) cuase

A

premature ovarian insuffiiency (POI)
can concieve with no treatment but pregnancy rates v low

70
Q

other options for managemnt of group 3 (ovarian fialure/insuffieincey) than conseravitely 5

A

IVF
emrbyo donation
adoption
fostering
accepting childlessness

71
Q

how are a womens fallopian tubes assessed for dysfunction in infertility 3

A

hysterosalpingogram (HSG)
-X-ray with radio-opaque dye into the uterus

laparosocpy and dye test
-consider risks assoc w laparscopy
-allows assessment of pelvis

hysterosalpingo-contras ultrasonography (Hy-Co-Sy)
-assess tubal and uterine pathology

72
Q

elegibiltiy in scotland for assissted conception services 5

A

-female must be less than 43 yo by time treatment is completed AND less than 42 years by time screening is completed

female BMI 18.5-30

both partners non smoking for at least 3 months before being placed on waiting lists

at least one partner have no biliogcla child

neither you or partner have been sterilied

cohabitng stable relationship for greater than 2 years

73
Q

what infections are tested for at cervical screening for assisted conception services 5

A

rubella

HIV
\
hep c

hep B

chlamydia

74
Q

techniques for assisted conception services

A

intrauterine insemination ± ovulation inducion

IVF- sperm feritlzies egg on its own

intracystosplasmic sperm injection
-singe sperm injected into mature egg

75
Q

rates of live birth rate for assisted conception serivecs

A

~25% for each cycle

Obs & Gyn (23 decks)

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