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RANZCOG -Gynaecology 2024 Edward > Infertility > Flashcards

Infertility Flashcards

1
Q

What are the indications for IVF (6)

A
  1. Ovarian causes
    -Anovulation despite ovulation induction
    -Hypogonadism or carriers of genetic mutation requiring donor egg
  2. Tubal disease
    -Severe disease
    -Tubal disease + other RF for subfertility
    -No spontaneous pregnancy after 6/12
  3. Uterine causes
    -IVF not indicated
  4. Unexplained
    -If failed IUI and COI x 3 (sperm + ovulation induction)
  5. Male factors
    -IVF or ICSI if severe
  6. Surrogacy
    -Medically contraindicated
    -No uterus
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2
Q

Describe ovulation induction
-Indications (4)
-Types (2)
-When to have UPSI
-Relationship to ovarian cancer

A
  1. Indications:
    -Hypogonadotrophic hypogonadism
    -Anovulation - PCOS, hyperprolactinemia (correct 1st)
    -Mild to moderate endometriosis
    -Unexplained infertility with IUI
  2. Types
  3. Monitored - check oestradiol and USS to review follicle formation D10 and mid luteal progesterone to assess ovulation
  4. Reviewed - D21 progesterone
  5. Timing of UPSI
    -If natural insemination - UPSI everyday/ 2 days from D11
    -If artificial insemination LH daily from D11 to assess surge then 36hrs post this
  6. No link between ovarian cancer and OI
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3
Q

What are the 6 methods of ovulation induction?

A
  1. Clomiphene - second line
  2. Letrozole - first line
  3. Metformin - not as good as clomifene or letrozole.
  4. Pulsatile GnRH therapy - 3rd line when no response to letrozole or clomifene
  5. Gonadotrophin therapy
  6. Ovarian drilling
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4
Q

Discuss clomifene in terms of ovulation induction.
-Medication family
-Mode of action
-Regimen
-SE (4)
-Risk of multiple pregnancy
-Risk of OHSS
-Risk of tetrogenicity

A
  1. SERM
  2. MOA
    -Acts centrally
    -Blocks the action of estradiol at the hypothalamus to increase FSH
    -Acts as an agonist for LH and FSH on granulosa cells to increase follicular development.
    -Can have negative impact on endometrium ? impacts pregnancy success rates
  3. 50mg daily for 5 days. Starting on day 2-5 of the cycle. Can increase up to 150mg
  4. Side effects
    -Hypoestrogenic effects, hot flushes, breast tenderness, N&V
  5. Risk of twin pregnancy - 10%, risk of triplets - 1%
  6. Risk of OHSS <1%
  7. No increased risk cf letrozole and spont pregnancies
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5
Q

Discuss letrozole in terms of ovulation induction.
-Medication family
-Mode of action
-Regimen
-Efficacy
-Risk of multiple pregnancy
-Risk of OHSS
-SE (2)
-Risk of tetragenicity

A
  1. Aromatase inhibitor
    -First line for OI
  2. MOA
    -Acts peripherally
    -Reversible binding to CYP450 to prevent conversion of testosterone and androstenedione to oestrogen and estrone = reduced negative feedback to hypothalamus
  3. Regimen
    2.5mg PO daily day 3-7 of cycle up to max of 7.5mg. Check D21 progesterone. USS and estrodiol levels not required but can be done
  4. Efficacy
    -20-30% will become pregnant after 3-4 cycles
    -Increased live birth rates compared with clomifene.
    -Similar rates of miscarriage, OHSS< multiple pregnancy cf. clomifene (Cochrane RV 2014
  5. Risk of multiple pregnancy <5%
  6. Fatigue and dizziness
  7. No increased risk of fetal malformations cf clomifene
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6
Q

Discuss GnRH pulsatile therapy for OI
-MOA
-When to use
-Efficacy
-Risk of pregnancy and OHSS

A
  1. MOA
    -GnRH stimulates LH and FSH production
  2. Third line treatment when letrozole and clomifene have not worked
  3. Ovulation rates 90%, pregnancy rates 80%
  4. Low risk multiples and OHSS
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7
Q

Discuss Gonadatrophin therapy for OI
-MOA
-When to use
-Regimen
-Efficacy
-Risk of pregnancy and OHSS

A
  1. Administration of recombinant FSH
  2. Fourth line treatment - if failure with letrozole and clomifene and no access to GnRH pump
  3. Give daily injections from D2-3. monitor follicle formation with TVUSS. When dominant follicle >18mm give HCG trigger
  4. Ovulation rate 72%, pregnancy rate 45%
  5. Risk of multiples 15-20% and increased risk OHSS
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8
Q

Discuss ovarian drilling for ovulation induction
-When to use
-MOA
-Risks
-Benefits
-Efficacy

A
  1. Consider if monitoring not possible or as fifth line
  2. Thermal destruction of theca cells increasing FSH and enhancing intrafollicular development
  3. Surgical morbidity, risk of oophorectomy if bleeding
  4. Can combine with dx lap, lower risk of multiples and OHSS, doesn’t require monitoring
  5. As effective at gonadatrophins in achieving pregnancy
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9
Q

Discuss intrauterine insemination
-Types (2)
-Indications for each type
-Requirements
-Regimen for each type
-Efficacy
-Risks (5)

A
  1. Types
    -Simple - semen is introduced to uterus 36hrs after ovulation
    -Controlled ovulation and IUI - OI + semen introduction to uterus 36hrs after ovulation
  2. Indications
    -Simple: frozen sperm sperm donor, obstructive male factor infertility
    -COI + IUI: Unexplained infertility, mild to moderate endometriosis, low sperm count or poor motility
  3. Requirements
    -Motile sperm in good numbers (do trial sperm wash)
    ->1 million total motile sperm
    -Confirmed tubal patency
  4. Regimens:
    -Simple: monitor LH levels and give 36hrs after LH surge
    -COI + IUI: track follicle formation by USS. Inject sperm at time of ovulation.
    -Ovulation can be spontaneous or triggered by HCG
    -Cannot use Sperm from testis aspirate as not enough. Much be ICSI
  5. Efficacy
    -Pregnancy rate 10-15% each round
    -Best if female <35yrs old
  6. Multiple pregnancy, OHSS (rare), ectopic pregnancy, infection and bleeding
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10
Q

Describe the steps of IVF (7)

A
  1. Suppression of natural cycle - stops ovulation and loss of eggs.
    -GnRH agonist protocol
    - causes downregulation of pituitary.
    - Takes about 2/52
    - Commence mid luteal phase of preceding cycle
    - Monitor suppression with oestrodiol levels. Once low can
    stimulate
    -GnRH antagonist protocol
    -Blocks GnRH receptors on pituitary and reduces LH/FSH
    production
    -Onset in a few days. Can start simulation immediately
  2. Stimulation
    -FSH daily injections for 2 weeks
    -Track follicular development by USS
  3. Trigger re entry into meiosis
    -Give once >2 follicles are >16mm
    -Usually HCG (much longer effect so increase OHSS)
    -GnRH agonist if using antagonist protocol and >20 follicles so at risk of OHSS. Don’t implant this cycle - freeze.
  4. Egg collection
    -Undertake 36hrs after trigger
    -Aspirate follicles before ovulation with USS guided needle
    -90% of follicles have an oocyte
  5. Fertilisation:
    -Incubate with sperm overnight
    -ICSI if male infertility factor
  6. Embryo transfer
    -Day 3-5
    -Single embryo is gold standard
    -place in uterine cavity under USS guidance
  7. Provide luteal support with HCG injections or vaginal progesterone
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11
Q

What are the ways sperm is collected for ICSI (3)

A

ICSI is used for severe male infertility factor
1. Methods of collection:
-Ejaculation
-Testicular aspiration (TESA)
-Epididymal aspiration (PESA)

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12
Q

What are the prognostic factors of IVF success (7)

A
  1. Age <35
  2. Shorter duration of infertility
  3. First IVF cycle
  4. Previous successful pregnancy
  5. Non smoker
  6. Salpingectomy prior to IVF if hydrosalpinges present
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13
Q

Discuss isthomocele/CS scar defect in relation to infertility
-Definition
-Incidence
-Sx (3)
-Risk factors
-Cause of infertility
-Diagnosis
-Management
-Follow-up advise

A
  1. Any visible defect in the anterior isthmus of the uterus on TV scan. >3mm is considered large
  2. 24-85% - uncommon to be symptomatic
  3. Presentation:
    -Secondary infertility OR 1.6 prev CS cf VB
    -AUB with post menstrual spotting / brown PV DC
    -Dysmenorrhoea ? adenomyosis in scar
  4. Risk factors
    -Previous CS
    -Long labour >5hrs, dilation >5cm, low station
    -Slow absorbing sutures, endometrium not included in layer, 1 x myometrial layer closure, scar ischemia
    -Oxytocin
  5. Accumulation of menstrual blood secondary to poor myometrial contractility
    -impacts cx mucous, sperm motility and viability
    -may impact blastocyst implantation
  6. Diagnosis
    -TVUSS
    -triangular hypoechoic zone
    -MRI - gold standard
    -Hysterosalpinogram or saline sonohysterography
    -Hysteroscopy or laparoscopy
  7. Management:
    -Medical - menstrual suppression if not desiring fertility
    -Surgical
    - hysteroscopic if myometrium >3mm thick
    - Laparoscopic if myometrium <3mm thick
  8. Follow-up advise
    Delay pregnancy >3/12 after procedure
    Recommend CS for next delivery due to rupture risk
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14
Q

Discuss OHSS (Ovarian hyperstimulation syndrome)
-Cause
-Types
-Incidence
-Risk factors
-Measures to prevent OHSS

A
  1. Systemic disease caused by vasoactive substances released by stimulated ovary (VEGF). Cause capillary permeability and third spacing with resulting intravascular dehydration.
    Levels of vasoactive substances raised by HCG
  2. Types of OHSS
    Early OHSS
    -Occurs within 9 days of HCG trigger.
    -Associate with exogenous HCG
    -Resolves in 10-14 days if woman not pregnant
    Late OHSS
    -Occurs >=10 days post trigger
    -Associated with endogenous HCG production.
    -More prolonged and severe
  3. Incidence
    -0.5% of OHSS requires hospitalisation
    -Mild OHSS - 30%
    -Moderate - 5%
    -Severe <1%
  4. Risk factors:
    -Lean, young age
    -PCOS, High AMH, Previous OHSS
    -HCG as trigger, superovulation >20 follicles, rapidly rising oestradiol, multiple pregnancy
  5. Prevention measures
    - Use GnRH antagonist cycle so can avoid HCG trigger
    -Recognise risk factors (>20 follicles, rapidly rising estrogen or >10,000)
    -With hold HCG trigger, with hold embryo transfer
    -Avoid HCG for luteal support - use progesterone
    -Consider cabergoline at time of trigger to reduce VEGF factor release
    -Dose with FSH according to RF for OHSS
    -Single embryo transfer
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15
Q

How does OHSS present
-Sx (5)
-Signs (6)
-Differential dx (5)

A
  1. Sx
    -Discomfort - not severe pain
    -Distension
    -N+V
    -SOB, Orthopneoa
    -Decrease urine output
  2. Signs
    -Tense acities
    -Hypotension
    -Tachycardia
    -Tachycapneoa
    -Hypoxia
    -Rapid weight gain
  3. DDx
    -Torsion
    -Ovarian haemorrhage
    -Infection (higher with endometrioma)
    -Ectopic
    -Appendicitis
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16
Q

What investigations should be undertaken for OHSS?
-Bloods
-Imaging
-Other

A
  1. Bloods
    -FBC, HCT (raised)
    -CRP - severity
    -U+E+Cr - hyponatremia, hyperkalemia, abnormal renal func
    -LFTs - low albumin
    -Serum osmolality - hypo osmolality
    -Coagulation profile - raised fibrinogen
    - HCG if embryo placed
  2. Pelvic USS to assess ascties and size of ovaries r/o torsion
  3. Daily weight and abdominal girth and fluid balance
17
Q

How is OHSS classified and what is the criteria for each? (4)

A
  1. Mild (30%)
    -Mild abdo distension/pain/bloating
    -Ovaries <8cm
    -Normal bloods
  2. Moderate (5%)
    -Mild features
    -N+/- V
    -Ultrasound evidence of ascites
    -Ovaries 8-12cm
    -HCT >41%, WCC >15
  3. Severe (<1%)
    -clinical ascites or hydrothorax
    -Oligo/anuria
    -Hypotension/SOB/Syncope/ Severe pain
    -HCT >45 Na <145 K>5 WCC >25 deranged LFTs
    -Ovaries >12cm
  4. Critical
    -anuria/renal failure
    -VTE
    -ARDS
    -pericardial effusion / arrythmia
18
Q

How should OHSS be managed:
1. General principles (2)
2. Outpatient setting
3. Inpatient setting

A
  1. General principles:
    Aim for supportive / symptomatic relief management.
    -Early OHSS resolves - 7 days
    -Late OHSS resolves 10-20 days
    -Avoid NSAIDS for pain relief
    Prevent:
    -VTE
    -Haemoconcentration
  2. Outpatient
    -Suitable if mild or moderate OHSS
    -Self monitor urine output / new or worsening symptoms and report.
    -Can do outpatient paracentesis of ascitic fluid
    -Check bloods every 2-3 days
    -Avoid sex and exercise - increased risk of torsion
  3. Inpatient
    -Suitable if moderate to critical
    -If severe or critical requires MDT approach with renal / ICU/ haem
    -Daily bloods / weight and abdo circumference
    -USS to assess ovary size and ascites
    -CXR if pleural effusion suspected
    -Strict fluid balance
    -IVF if HCT >45 or UO >30mL/hr
    - IDC if oligouric
    -Consider albumin if ongoing oligouria - 20% albumin
    -Consider transabdominal paracentesis
    -Replace drained loss with albumin
    -VTE prophylaxis
19
Q

What are the risks from OHSS to the ongoing pregnancy (4)

A
  1. Increased risk of miscarriage
  2. PET if severe OHSS
  3. PTD if severe OHSS
  4. No increase in congenital abnormalities
20
Q

What are the proposed mechanisms whereby endometriosis impacts fertility (4)

A
  1. Endometriosis is present in 50% of women with infertility
  2. Mechanism of action
    In mild to moderate endometriosis
    -Proinflammatory state to endometriosis deposits impacts gametes, tubal motility, folliculogeneisis
    -Local inflammation impacts blastocyst implantation and endometrial receptivity
    In severe disease:
    -Adhesions and endometriomas impact oocyte release, sperm transport, tubal function and reduce endometrial reserve
    -Increased miscarriage rate and ectopic pregnancies
21
Q

How should infertility be managed in those with endometriosis?

A
  1. Conservative management - 43% will spontaneous conceive after 1yr
  2. Medical management
    -No evidence for hormonal management pre or post op improve pregnancy rates
    -Consider GnRH for 3-6 months prior to ART in those women who have undergone surgical resection of endometriosis
  3. Surgical management
    -Excision of stage 1-2 endometriosis is associated with better spontaneous contraception
    -Excision is better than ablation
    -Surgical management doesn’t effect ART outcomes
    -Surgical management of stage 3 or 4 endometriosis not associated with better spontaneous conception
    -No evidence excision of endometriomas improves spontaneous pregnancy or ART success but can consider (ESHRE guidelines)
    -No evidence surgical excision of DIE improves pregnancy outcomes
  4. ART
    -Stage 1 and 2 - COI + IUI improves birth rates
    -Stage 3 no evidence that surgical treatment pre procedure improves ART outcomes.
    -Stage 3 ad 4 consider COI + IUI but no evidence.
    -Doesn’t increase recurrence rates
22
Q

How should endometriomas be managed for women desiring pregnancy:
1. Impact of management on pregnancy outcomes
2. Options for management
3. Risks for each option
4. Who to consider for each option
5. Best surgical approach

A

Management of conservative vs surgical resection of endometriomas is controversial
-No evidence removal improves spont pregnancies or ART success
-Base on symptoms, size of cyst, surgical risk, concern for Surgical removal:
Risks: reduce egg reserve, damage to surrounding structures, requires higher FSH for OI.
Consider in women prior to IVF with: unilateral cyst, symptomatic, radiologically suspicious for malignancy, good AMH
Excision are superior to drainage for spontaneous conception (RR= 5)
Conservative management:
Can mean egg retrieval is difficult, increased risk of infection, bleeding, damage to surrounding structures
Risks: Miss malignancy and complications of egg collection
Consider in women with: low AMH, AMA, asx, bilateral endometriomas

23
Q

Discuss female infertility
-Definition of infertility
-Definition of sterility
-Definition of fecundity
-Incidence of primary infertility and secondary infertility
-Incidence of conceiving by 1 yr and by 2 yrs
-Incidence of infertility overall

A
  1. Infertility = inability to fall pregnant with regular UPSI in 1-2 yrs
  2. Sterility - no ability to conceive
  3. Fecundity - the reproductive capacity of an individual over time - stated as monthly or yearly
  4. Epidemiology
    Incidence of primary infertility - never been pregnant - 70%
    Incidence of secondary infection - previous pregnancy - 30%
  5. Overall 85% of ppl conceive within 1 yr and 92% within 2yrs
  6. Overall infertility seen in 1:6 couples (15%)
24
Q

What are the causes of female infertility and how common are they? (7)

A
  1. Disorder in both partners - 39%
  2. Unexplained 30% - 40%. 8-28% of couples
  3. Ovulation 27%
  4. Semen quality 19%
  5. Tubal function 14%
  6. Endometriosis 5%
  7. Other 5%
25
Q

Discuss the ovarian causes of female infertility
-3 main causes
-Examples in each main group

A
  1. Hypogonadotrophic hypogonadism
    -hypothalamic failure to produce pulsatile GnRH
    -Functional: stress, low weight, excessive excercise
    -CNS lesion, head injury, infiltrating disease, Kallmans, irradiation
    -At level of pituitary - prolactin secreting tumour, Sheehans
  2. Hypergonadotrophic hypogonadism
    -Failure of ovary to respond to gonadotrophs
    Premature ovarian failure - CAR PIG
    -Chromosomal - Turners, Swyers. Autoimmune, Rad/Chemo/Surg, Primary ovarian insufficiency, Infection - mumps, Genetic - Fragile X, Resistant ovary syndrome, galactosaemia
  3. Endocrine
    -PCOS - 80% of all ovarian causes
    -Hyperprolactinemia - adenoma’s or drugs
    -Hypothyroidism
    -Adrenal CAH, Cushings, virilising adrenal tumours
26
Q

Discuss the tubal causes of female infertility
5 main causes

A
  1. Infection - PID increased risk with increased episodes
  2. Pelvic infection - appendicitis, Cronhns, septic miscarriage, TB
  3. Endometriosis
  4. Tubal surgery
  5. Salpingitis isthmica nodosa -diverticular of the distal tube
27
Q

Discuss the uterine causes of female infertility
-4 main causes

A
  1. Intrauterine adhesions
    -Trauma, endometriosis
  2. Submucosal fibroids
    -Cavity distortion or tubal obstruction
  3. Congenital uterine anomalies
    -septum likely associated with infertility
    -Didelphys, uni or bicornuate unlikely to impact fertility
  4. Isthomocele
28
Q

Describe the investigations for infertility work up:
7 parameters

A
  1. General pregnancy
    -First AN screening
    -STI screening - Hep B/C/HIV
    -Smear
  2. Evaluation of ovarian reserve
    -D2-5 oestradiol, FHS and LH
    -FSH <10 oestradiol <200 = normal
    -AMH - doesn’t predict fertility, age dependant. Predicts OHSS developing, number of eggs likely retrieved in IVF, early menopause
    -Prolactin
    -TSH
    -Androgen profile: testosterone, SHBG, DHEA
    -Carrier screening
  3. Ovulation occurring
    -mid luteal progesterone >30 = ovulation
  4. Uterine defects
    -USS - for uterine defects / ovarian cysts
    -Hysteroscopy
  5. Tubal patency
    -Hysterosalpingogram
    -Laparoscopy and tubal dye studies
    -Hysterosalpingo contrast sonography
29
Q

Discuss methods of assessing tubal patency
-Types (4)
-MOA
-Advantages
-Disadvantages of each

A
  1. Hysterosalpingogram - HSG
    -Standard investigation unless planning lap
    -Inject radio-opaque dye through cervix while taking XR-Advantages
    - assesses tubal patency and location of obstruction.
    -Highly sens and spec for distal tubal occlusion
    -Some theraputic effect with increased conception rates
    Disadvantages
    -Increased risk infection
    -can’t assess peri-tubal adhesions or endometriosis
    -Not so good for proximal occlusions - need lap as 2nd step
    -Can over estimate occlusion due to tubal spasm
  2. Hysterosalpingo contrast sonography - HyCoSy
    -Transcervical injection of contrast media with USS used to visualise tubes
    Advantages
    -provides more info about endometrium, myometrium and adnexa.
    -Better tolerated than HSG
    -92% sensitive
    Disadvantages - infection. Operator dependent
  3. Hysteroscopy
    -Not really useful for looking at tubes but can identify and treat uterine anomalies
  4. Laparoscopy + tubal flushing
    -Methylene blue / saline is injected tranuterine and tubal spill is assessed
    Advantages:
    -can treat adhesions and endo at same time
    Disadvantages
    -Expensive, doesn’t assess internal contour of tube or endometrium, higher surgical complications
30
Q

Describe the management for infertility according to cause:
-General interventions (4)
-Anovulation
-Tubal factors
-Endometriosis
-Uterine factors
-Unexplained

A
  1. General interventions
    -Normalise BMI, smoking cessation, reduce etOH, regular UPSI
  2. Anovulation
    -consider for hypogonadotrophic hypogonadism + PCOS
    -OI with letrozole, clomifen, pulsatile GnRH, Gonodatrophic injection
  3. Tubal factors
    -Surgery to resolve tubal obstruction
    -Bilateral salpingectomies + IVF - if hydrosalpingies
    -fimbrioplasy to open fimbrial end
    -Salpingostomy to open distal end
    -Neosalpingostomy - new distal opening at fimbrial end
    -TL reversal - 85% with filshe clip removal
    -If no success with tubal surgery, hydrosalpinx, AMA, or tubes damaged ++ = for IVF
  4. Endometriosis
    -Excisional surgery increases spont preg rate but not IVF success
    -Consider COI + IUI in mild to moderate cases
    -No role for meds unless GnRH 3-6 months post surg and pre IVF
  5. Uterine factors
    -Hysteroscopic resection of submucosal fibroids, septa (unclear if treating improves conception rates), polyps
    -Hysteroscopic division of adhesions
  6. Unexplained
    Expectant
    -Continue to have UPSI - 60% conceive in 5 yrs
    COI + IUI or COI + timed sexual intercourse
    -Pregnancy rate 10-15%
    -IVF if no success after 3 cycles of COI + IUI
31
Q

What are the causes of male factor fertility
-4 main causes

A
  1. Hypogonadotrophic hypogonadism - CARPIG
    Genetic - Kallmans
    Acquired - Pituitary adenoma, infiltrative, infection, trauma, chemo/rad/surg, severe illness, hormone excess - endogenous / exogenous
  2. Hypergonadotrophic hypogonadism
    -Congenital - androgen insenitivity, 5 alpha reductase
    cryptokidism, klienfelters, Y chromosome microdeletions
    -Acquired - mumps/ orchitis, trauma, torsion, cancer, radiation/chemo/surg/ drugs, smoking, etOH, heat, fumes
  3. Sperm transport disorder
    -congential - No Vas def
    -Acquired - varicoele, infection, vasectomy
  4. Idiopathic
32
Q

What is the definition for the following:
1. Azoospermia
2. Oligospermia
3. Teratozoospermia
4. Hypospermia

A
  1. Absent sperm
  2. Sperm count <15 million sperm / mL
  3. Abnormal sperm morphology
  4. Reduced volume of ejaculation
33
Q

What is tested for in semen analysis and what are normal values

A
  1. Volume >=1.5mL
  2. pH 7.2
  3. Sperm concentration >= 15million / mL
  4. Total sperm count >=39 million / ejaculate
  5. Progressive motility >=32% - most prodictive
  6. Total motility >=40%
  7. Morphology >=4%
  8. Vitality >= 58% of sperm alive

Can also look at
1. Seminal fructose - can indicate obstruction
2. Antisperm antibodies - if hx suggestive of breach of testes blood barrier or reversal of vasectomy

34
Q

What are the investigations for male infertility (9)

A
  1. Gonoadatrophins - FSH, LH testosterone
    -Normal FSH and testosterone = possibly obstructive
    -Low FSH and low testosterone = hypo hypo
    -High FSH and normal testosterone = failure of spermatogenesis
    -High FSH and low testosterone = testicular failure
  2. Karyotype
    -Y chromosome microdeletions, XXY, CF
  3. Testicular USS
    -Unclear if should be routine. Can do if semen analysis abnormal
  4. Testicular Bx
    -Assess if sperm available for ICSI
  5. Antisperm antibodies
    -If Hx suggestive
  6. Endocrine investigations
    -Prolactin
    -Thyroid
  7. Can do STI screen but not routine
  8. Post ejaculate urine samples if concern for retrograde ejaculation
  9. Semen analysis
35
Q

What are the RANZCOG recommendations for ART in AMA mothers (5)

A

AMA is considered >45 yrs in this guideline
1. Full caridac evaluation should be done prior to offering ART as well as review for other co-morbidities
2. If the Dr thinks risk precludes treatment a second opinion should be sought
3. Single embryo transfer should be done. Not multiples
4. A Dr should consider the efforts of assisting a person to get ART overseas when this service would not be demed safe in NZ or Australia
5. Women should have full clear information regarding risks of pregnancy in AMA

36
Q

Discuss management of endometriomas for infertility
-Reasons for cystectomy (3)
-Reasons for avoiding surgery (4)

A
  1. Reasons for cystectomy
    -May improve spontaneous conception in pts with good prognosis factors
    -Reduces risk of infection with egg collection
    -Gives histological dx (Small chance of cancer)
  2. Reasons for avoiding surgery
    -Avoid reduction in ovarian reserve
    -Avoids surgical risk
    -Risk of occult cancer
    -No difference in IVF outcomes with removal vs remaining insitu
37
Q

Describe the management for infertility according to cause:
-General interventions (4)
-Anovulation
-Tubal factors
-Endometriosis
-Uterine factors
-Unexplained

A
  1. General interventions
    -Normalise BMI, smoking cessation, reduce etOH, regular UPSI
  2. Anovulation
    -consider for hypogonadotrophic hypogonadism + PCOS
    -OI with letrozole, clomifen, pulsatile GnRH, Gonodatrophic injection
  3. Tubal factors
    -Surgery to resolve tubal obstruction
    -Bilateral salpingectomies + IVF - if hydrosalpingies
    -fimbrioplasy to open fimbrial end
    -Salpingostomy to open distal end
    -Neosalpingostomy - new distal opening at fimbrial end
    -TL reversal - 85% with filshe clip removal
    -If no success with tubal surgery, hydrosalpinx, AMA, or tubes damaged ++ = for IVF
  4. Endometriosis
    -Excisional surgery increases spont preg rate but not IVF success
    -Consider COI + IUI in mild to moderate cases
    -No role for meds unless GnRH 3-6 months post surg and pre IVF
  5. Uterine factors
    -Hysteroscopic resection of submucosal fibroids, septa (unclear if treating improves conception rates), polyps
    -Hysteroscopic division of adhesions
  6. Unexplained
    Expectant
    -Continue to have UPSI - 60% conceive in 5 yrs
    COI + IUI or COI + timed sexual intercourse
    -Pregnancy rate 10-15%
    -IVF if no success after 3 cycles of COI + IUI

RANZCOG -Gynaecology 2024 Edward (11 decks)

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