Infertility Flashcards

1
Q

how are the psychological effects of fertility problems managed?

A
  • inform that they may find a fertility support group helpful.
  • a/v that stress in their relationship may reduce libido and frequency of intercourse, and that this may reduce fertility.
  • offer counselling before, during and after investigation and treatment, and this should be by someone who is NOT directly involved in the management of the couple’s infertility problems.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

effect of smoking on fertility?

A

women who smoke are likely to have reduced fertility, and should be offered r/f to a smoking cessation programme.
passive smoking is also likely to affect a woman’s chance of conceiving
smoking in men is associated with reduced semen quality, and stopping smoking will improve general health.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

when should further assessment and investigation for infertility be offered to a woman and her partner who are trying to conceive?

A

if the woman if of reproductive age and has not conceived after 1 year of unprotected vaginal sexual intercourse, in the absence of any known cause of infertility.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

after how many cycles of treatment should further assessment and investigation for infertility be offered to a woman trying to conceive using artificial insemination?

A

after 6 treatment cycles, in the absence of any known cause of infertility.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

when is earlier r/f to a specialist indicated in infertility?

A

woman aged 36 or older

of known clinical cause of infertility or history of predisposing factors.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

examples of disorders of ovulation that may be responsible for female infertility?

A

-PCOS-cause of hypothalamic-pituitary-ovarian dysfunction
-hypothalamic problems-excessive exercising, underweight. kallmann’s syndrome-congenital lack of hypothalamic prod. of GnRH, causes amenorrhoea and anosmia.
-pituitary problems-pituitary tumours-may destroy normal tissue-FSH and LH prod. usually 1st affected, may be panhypopituitarism=simmonds’ disease, hyperprolactinaemia-note prolactin can be increased with raised TRH prod. as occurs with hypothyroidism as TRH stimulates TSH AND prolactin release.
sheehan’s syndrome-anterior pituitary infarct following PPH
-thyroid disorders
-Cushing’s syndrome, CAH
-ovary problems-premature ovarian failure
chromosomal disorders-turner’s syndrome, testicular feminisation-androgen insensitivity, karyotype XXX-fertility often normal but may cause premature ovarian failure.
-chronic debilitating disease that may cause anovulation and amenorrhoea including uncontrolled diabetes, cancer, AIDs, end stage CKD and malabsorption.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

f/u if 1st semen analysis is abnormal?

A

offer rpt confirmatory test, ideally 3mnths after initial to allow time for cycle of spermatozoa formation to be completed
BUT if gross spermatozoa deficiency then rpt test should be done as soon as possible.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

what measures are used to predict likely ovarian response to gonadotropin stimulation in IVF?

A
  • total antral follicle count
  • anti-mullerian hormone-secreted by ovarian follicle cells
  • FSH
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

at what stage of the menstrual cycle is a serum progesterone test offered in the investigation of female infertility?

A

day 21 of a 28 day cycle
or 7 days prior to 1st day of next predicted menstrual bleed, may need to be repeated weekly thereafter until next menstrual cycle starts.

test to see if pt ovulating

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

which women should be offered serum gonadotropin tests in investigation of infertility?

A

FSH and LH blood test in those with irregular menstrual cycles.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

which women should be offered prolactin testing in investigation of inferility?

A

those with an ovulatory disorder, pituitary tumour or galactorrhoea.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

problems of fallopian tubes, uterus or cervix that can cause female infertility?

A
  • PID
  • postpartum infection
  • STIs
  • previous pelvic surgery-adhesion formation
  • Uterus and cervical adhesions-asherman’s syndrome-result of infection
  • uterus deformity-septum or bicornuate uterus, may be more likely to cause recurrent miscarriage
  • fibroids-causing significant uterine cavity distortion e.g. submucosal fibroids
  • shortened/damaged cervix due to cone biopsy or cervical surgery
  • endometriosis-tubal distortion and limitiation of fimbrial motility with adhesions
  • previous sterilization
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

define primary amenorrhoea

A

failure of menses to occur by 16 years of age, in presence of normal growth and secondary sexual characteristics, or by 14 when no secondary sexual characteristics present.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

define secondary amenorrhoea

A

absence of menstruation for at least 6 mnths in women with previously normal and regular menses, or for 12 mnths in those with previous oligomenorrhoea.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

characteristic features of PCOS?

A
  • irregular menses, oligomenorrhoea, amenorrhoea
  • infertility
  • features of hyperandrogenism-hirsutism, acne, male pattern alopecia
  • obesity
  • insulin resistance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

causes of female infertility other than disorders of ovulation or tubal, uterine or cervical factors?

A
  • drugs e.g. NSAIDs-inhibit ovulation, spironolactone-menstrual irregularities, neuroleptics, recreational e.g. cocaine, chemotherapy with cytotoxics-ovarian failure.
  • occupation and environ exposure-pesticides, metals-lead, cadmium, and formaldehyde.
  • stress
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

cause of excess androgen production by ovaries in PCOS?

A

increased LH and hyperinsulinaemia-occurs as a result of insulin resistance, and this resistance becomes worse with weight gain
note that insulin inhibits hepatic production of sex hormone binding globulin, so although total testosterone may be normal or only modestly increased, free unbound testosterone is elevated
increase LH concentration relative to FSH switches ovary production of oestrogens to androgens

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

why does endometrial hyperplasia occur in women with PCOS?

A

anovulatory cycles, so oestrogen produced as as ovarian follicle develops, but fails to rupture to cause corpus luteum production and progesterone production, so continued exposure to unopposed oestrogen
AND high androgen levels, testosterone converted to oestrogen in adipose tissue.

19
Q

complications of PCOS?

A
infertility
problems in pregnancy-gestational diabets, pregnancy induced HTN, pre-eclampsia, premature delivery, small for dates
endometrial cancer
type 2 DM and impaired glucose tolerance
CVD
dyslipidaemia
sleep apnoea
20
Q

investigations that could confirm PCOS diagnosis?

A

total testosterone-more than 5nmol/L
sex hormone binding globulin-normal or low
can then calculate free androgen index-would expect higher than normal (less than 5)
LH-may be elevated, increased LH:FSH, but this is not part of the diagnostic criteria
pelvic ultrasound

21
Q

diagnostic criteria for PCOS?

A

2 of the following 3 criteria met:

  • infrequent or no ovulation-oligo or amenorrhoea
  • clinical or biochemical signs of hyperandrogenism e.g. hirsuitism, acne, male pattern alopecia, or elevated levels of total or free testosterone
  • polycystic ovaries on US-12 or more follicles in at least 1 ovary, or increased ovarian volume (more than 10ml).
22
Q

initial investigations in woman presenting with infertility?

A
  • mid luteal serum progesterone-day 21 of 28 day cycle, or 7 days before predicted date of next bleed, to see if pt is ovulating
  • LH and FSH-exclude premature ovarian failure and hypogonadotropic hypogonadism
  • TSH-in those with thyroid symptoms
  • prolactin-if ovulatory disorder, pituitary tumour or galactorrhoea, may be mildly elevated in PCOS
  • screen for chlamydia
23
Q

secondary care investigations of woman presenting with infertility?

A

hysterosalpingography or hysterosalpingo-contrast ultrasonography-screen for tubal occlusion in those not known to have comorbidities e.g. PID, prev ectopic or endometriosis.
if known comorbidites do laparoscopy and dye so tubal and other pelvic pathology can be assessed at the same time.

24
Q

medical options for ovulation induction?

A

-clomiphene-binds to oestrogen receptors on hypothalamus inhibiting negative feedback of oestrogen to increase FSH release. given as 50 mg OD for 5 days, to be started within about 5 days of onset of menstruation (preferably on 2nd day) or at any time (normally preceded by a progestogen induced withdrawal bleed) if cycles have ceased, followed by 100 mg daily if required for a further 5 days, this second course may be given in absence of ovulation.
3 courses=adequate trial, should not be used for more than 6 cycles as possible increased risk of ovarian cancer.
-metformin
-or combination of the 2
-gonadotropins-if clomiphene resistant anovulatory infertility, but significant risk of multiple pregnancy.
-pulsatile GnRH and dopamine agonists-may be used in hyperprolactinaemia.

25
Q

treatment for infertility, other than medical treatment?

A
  • surgery-tubal microsurgery, ablation or resection of endometriosis and/or lap adhesiolysis in endometriosis, surgical correction of epididymal blockage.
  • assisted conception-intrauterine insemination (sperm put inside uterus via plastic tube around time of ovulation), IVF (1 or more eggs removed and mixed with sperm, incubated for 2-3days then embryo injected into uterus via cervix), intracytoplasmic sperm injection (sperm injected into egg, used if low sperm count or can’t maintain erection and ejaculation e.g. DM, spinal cord injury), donor insemination, oocyte donation, embryo donation, gamete intrafallopian transfer.
26
Q

viral testing required in couples undergoing IVF?

A

HIV, Hep B and C

27
Q

what criteria should be met for negligible risk for HIV transmission from male to female partner through unprotected intercourse?

A

-the man is compliant with HAART
-the man has had a plasma viral load of less than 50 copies/ml for more than 6 months
-there are no other infections present
unprotected intercourse is limited to the time of ovulation

28
Q

management of women with hypothalamic pituitary failure?

A

increase body weight if BMI less than 19 and/or moderate their exercise levels if undertake high levels of exercise.
pulsatile administration of GnRH or gonadotropins with LH activity to induce ovulation.

29
Q

monitoring necessary for woman given clomiphene to induce ovulation?

A

US during at least 1st cycle of treatment to ensure taking a does that minimises the risk of multiple pregnancy

treatment should not be continued for more than 6 mnths (risk of ovarian cancer)

30
Q

monitoring necessary for woman given gonadotropins to induce ovulation?

A

ovarian US monitoring to measure follicular size and number to reduce risk of multiple pregnancy and ovarian hyperstimulation syndrome.

31
Q

surgical treatment for ovarian endmetriomas to improve change of pregnancy?

A

lap cystectomy

note medical treatment of endometriosis does not enhance fertility

32
Q

after what time can women with unexplained infertility be offered IVF?

A

after 2 years of not conceiving despite regular intercourse

33
Q

when can IVF be offered to women under the age of 40 having regular intercourse?

A

if not conceived after 2 years of regular unprotected intercourse, or 12 cycles of artificial insemination (where 6 or more are intrauterine)
offer 3 full cycles, with or without intracytoplasmic sperm injection.

34
Q

what do you want to ask in the history of female with infertility?

A
  • age
  • smoking status
  • length of time trying to conceive
  • how long not used contraception, and what their previous contraception was-?retained IUD
  • frequency of intercourse and any problems
  • number of children-same or previous partner, and prev. miscarriages, if prev. children then secondary infertility
  • ?ovulation problems-oligomenorrhoea, amenorrhoea, cyclical pain. hirsutism. galactorrhoea. systemic disease-thyroid, IBD, DM. excessive exercise, weight loss, stress.
  • ?tubal problems-prev. STIs and their treatment, symptoms of PID and endometriosis-PV bleeding, discharge, dyspareunia, chronic pelvic pain. previous pelvic surgery e.g. appendicitis. C smear history.
  • DH
  • occupation
35
Q

what are you looking for o/e of pt with infetility?

A

gen examination-body habitus, acne, hirsutism, features of thyroid disease, galactorrhoea.
abdo exam-palpable fibroids, scars-prev pelvic surgery
pelvic exam-discharge, cervical motion tenderness, adenexal tenderness, mass-ovarian cyst?, fibroids.

36
Q

questions to ask in history of male with fertility problems?

A

-age
-children with current partner and previous partners
-frequency of intercourse and problems
-length of time trying to conceive
-symptoms: previous mumps, STIs, testicular trauma or torsion
prev urogenital abnormality and treatment e.g. undescended testes
systemic diseases-uncontrolled DM, HF, renal failure, cancer
previous surgery e.g. hernia repair
-ejaculatory or erectile dysfunction
-DH
-occupation
-lifestyle

37
Q

what initial blood test apart from mid luteal progesterone should be done in investigation of woman for infertility who has irregular periods?

A

serum gonadotropins
high FSH suggests premature ovarian failure
low FSH and LH suggests hypothalamic hypogonadism

38
Q

initial investigations in male partner for infertility?

A

semen analysis

chlamydia screen

39
Q

infertility treatment for men with obstructive azoospermia?

A

surgical correction of epididymal blockage

40
Q

how can chance of success of intrauterine insemination be increased?

A

low doses of ovary stimulating hormones e.g. anti-oestrogen e.g. clomiphene, and gonadotropins

41
Q

RFs for ovarian hyperstimulation syndrome (OHSS)-systemic disease caused by vasoactive product release from hyperstimulated ovaries?

A

young age
lean physique
PCOS
multiple gestation

42
Q

risks associated with infertility treatment?

A

ovarian hyperstimulation syndrome (OHSS)
multiple gestation
EP and heterotopic pregancy
PID-infection introduced following needle extraction of eggs from ovaries.

43
Q

treatment of ovarian hyperstimulation syndrome? (OHSS)

A
  • fluid replacement

- thromboprophylaxis

44
Q

pathophysiology of OHSS?

A

complication of ovarian stimulation in some forms of infertility treatment
it’s thought that the presence of multiple luteinized cysts within the ovaries raise levels of oestrogens but also vasoactive substances e.g. VEGF, which increases membrane permeability and fluid loss from intravascular compartment.