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4th Year GOSH > Infertility > Flashcards

Infertility Flashcards

1
Q

General recommendations to help fertility?

A

Preconceptional Supplements (folic acid and vitamin D)
Environmental factors (occupation/drugs)
Stop smoking
Females no alcohol, male limit alcohol
BMI - female <19 >30 is bad, male >30 is bad

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2
Q

How much sex to optimise fertility?

A

Every 2/3 days

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3
Q

Four types of infertility and their prevalence?

A

Anovulatory - 30%
Male factor - 35%
Tubal factor - 30%
Unexplained - 15%

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4
Q

Three types of anovulatory disorder?

A

Ovarian - PCOS, premature ovarian insufficiency
Pituitary - hyperprolactinaemia, hypopituitarism
Hypothalamic - hypogonadism

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5
Q

Causes of hypothalamic hypogonadism?

A

(Low FSH, v low LH, low oestrogen)

oWeight loss and over-exercise
o Systemic illness
o Idiopathic Hypogonadotropic hypogonadism
o Kallman’s syndrome – GnRH secreting neurones fail to develop.

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6
Q

What is GnRH level in hypopituitarism?

A

GnRH normal - can result from tumours, or infarction following Sheehan’s syndrome.

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7
Q

What do you do in hyperprolactinaemia?

A

(Reduces GnRH release –> Low FSH, low LH, Low oestrogen)

Give dopamine agonist
• 85% will get restored ovarian function
• 85% will conceive
• If cause is macroadenoma, 50% will concieve

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8
Q

Ways of detecting ovulation?

A
  • Mid-luteal phase serum progesterone (standard test)
  • USS follicular tracking (time-consuming)
  • Temperature charts (not recommended)
  • LH-based urine predictor kits (ovulation should follow LH surge)
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9
Q

3 groups of ovulatory disorder?

A
  • Group I: hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism).
  • Group II: hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome).
  • Group III: ovarian failure.
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10
Q

Clinical features of Group 1

(Hypogonadotrophic/ Hypothalamic hypogonadism)?

A
  1. Low energy availability/ eating disorders
  2. Low bone mass
  3. Menstrual disturbance
    (Female athlete triad)
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11
Q

Hormone levels in Group 1 disorder?

A 
Oestrogen = Low
FSH = low/ normal
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12
Q

Management of group 1 disorder?

A

If BMI <19 – increase weight.
If high exercise levels – moderate exercise.
Gonadotrophins for ovulation induction.

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13
Q

Clinical features of group 2 (PCOS)?

A
  1. Polycystic ovaries on USS
  2. Clinical/biochemical hyperandrogenism
  3. Oligo/anovulation
    (Rotterdam criteria)

At increased risk of developing hypertension, diabetes and sleep apnoea later in life.

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14
Q

Hormone levels in PCOS?

A 
Oestrogen = Low
FSH = low/ normal
Oestrogen = normal
FSH = normal
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15
Q

Management of PCOS?

A

Clomifene
Metformin
Gonadotrophins
Ovarian diathermy

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16
Q

What is clomifene?

A
  • 1st line in PCOS – oestrogen receptor blocker –> increases FSH/LH (fools pituitary into thinking there is no oestrogen) – given from day 2 to day 6. Limited to 6 months’ use.
  • Multiple pregnancy more likely
17
Q

Which two treatments for PCOS make multiple pregnnacy more likely/

A

Clomifene

Gonadotrophins

18
Q

Clinical features of group 3 (premature ovarian insufficiency)?

A
  1. Oligo/amenorrhoea for at least 4 months
  2. Elevated FSH level >25 IU/L on two occasions >4 weeks apart
  3. Low oestrogen (vasomotor symptoms, osteoporosis)

(Loss of ovarian activity before 40 years)

19
Q

Hormone levels in group 3 (premature ovarian insufficiency)?

A 
Oestrogen = low
FSH = high
20
Q

Tests in group 3 disorders?

A

Karyotype – Turner Syndrome (45X) –> Refer to endocrinologist, cardiologist and geneticist

Karyotype – Chromosomal Material –>Discuss gonadectomy

Fragile X –> Refer to geneticist (Implication to family members)

Anti-adrenal antibodies –> Refer to endocrinologist

Thyroid peroxidase antibodies –> Test TSH every year

21
Q

Fertility treatment for premature ovarian failure/

A 
Fertility Treatment
•	Oocyte donation
•	No interventions shown to increase ovarian activity and natural conception rates
.
Hormone replacement therapy
22
Q

What is ovulation induction?

A

• Aim – unifollicular growth
o Timed with urinary LH/hCG administration
o Timed sexual intercourse.

23
Q

Risk factors for primary ovarian insufficiency?

A

• Modifiable Risk Factors
o Gynae surgical practice
o Stop smoking
o Modified treatment regimens.

•	Non-modifiable risk factors
o	Chromosomal (e.g. Turner’s XO)
o	Fragile X
o	FNA e.g. BPES
o	Adrenocortical/thyroid antibodies
o	Idiopathic
24
Q

Consequences of premature ovarian insufficiency?

A

Reduced life expectance due to cardiovascular disease
 Atherosclerosis
 Turner’s associated with congenital DVS

Decreased bone mineral density
 No oestrogen – need DEXA scan, healthy lifestyle and vitamin D
 Can give HRT – you are supplementing what isn’t there so is not dangerous.

Fertility – small chance of pregnancy – need contraception

25
Q

Types of male factor infertility

A
  • Oligozoospermia = <15 million sperm
  • Asthenzoospermia = reduced sperm motility
  • Teratozoospermia = abnormal sperm morphology
26
Q

Causes of male factor infertility?

A

Most causes not reversible

o Idiopathic (most common cause)
o Hypogonadism (10%)
o Genetic causes (Needs to be excluded before ICSI) - CF
o Testicular trauma / surgery / developmental abnormalities (cryptorchidism)
o Obstructive (surgery – vasectomy / infection)
o Anabolic steroid induced (not always be reversible)
o Previous chemotherapy / radiation

27
Q

What is the only medically treatable cause of male factor infertility?

A

Hypogonadism (low FSH/LH)

 Stop drugs – anabolic steroids most common cause.
• No guarantee it will come back
 Treat hyperprolactinaemia
 Pulsatile gonadotrophing and hCG
 Testosterone alone will not induce spermatogenesis
• Must have LH and FSH

28
Q

Causes of tubal factor infertility?

A 
o PID (chlamydia)
o Endometriosis
o Past abdominal/pelvic infection or surgery (appendicitis) 
o Treatment to cervix
o Fibroids/polyps
29
Q

Investigations in tubal factor infertility?

A

o Hysterosalpingography
 Appropriate for low risk women

o Hysterosalpingo-contrast-ultrasonography
 Alternative to HSG with no radiation exposure

o Laparoscopy
 The gold standard

o Always screen for chlamydia and other pathogens before test.

30
Q

When is IVF recommended?

A

If all other causes are excluded, IVF is recommended after two years of trying.

31
Q

What is intrauterine insemination?

A

o Follicle development tracked ultrasonographically
o Sperm prepared
o Placed in uterine cavity with USS

32
Q

What is the aim of IVF?

A

oAim for: controlled multi-follicular growth

33
Q

What is the process for IVF?

A

 Hormones (gonadotrophins) taken by the woman as injections cause the ovary to make several eggs at the same time (multifollicular recruitment)

 Egg collection 36 hours later (Sedated transvaginal procedure)

 Oocytes and sperm incubated together overnight
• The fertilised eggs (embryos) grow under observation in the laboratory for two to six days
• Selection process - to identify embryo(s) with the best chance of continuing to develop into a baby

 Embryo transfer to uterus (like a smear test)
 Give woman progesterone for luteal support

 Pregnancy test 2 weeks after transfer to see if successful
 First pregnancy ultrasound scan is performed 3 weeks later.

34
Q

What is intracytoplasmic sperm injection?

A

o Similar protocol to IVF
o Indicated in severe MF infertility
o Single sperm injected into denuded oocyte.

35
Q

Dangers of fertility treatment?

A

Ovarian hyperstimulation syndrome (OHSS)

Multiple pregnancy

36
Q

What is OHSS?

A

Iatrogenic process
 Vasoactive product released from ovaries
 Increased capillary permeability, fluid accumulation in the abdomen and severe dehydration due to loss of vascular fluid – LIFE THREATENING.
 Young, PCOS, pregnant

37
Q

Options for fertility preservation in men?

A

• Advisable prior to any therapy that potentially affects fertility - Chemotherapy, Radiotherapy, Surgery (Testicular, Reproductive tract, Retroperitoneal nerve plexus (para-aortic node dissection))

• Postpubertal boys and adults
o Sperm cryopreservation

• Prepubertal boys (currently no clinically available option)

38
Q

Options for fertility preservation in women?

A

• GnRH analogues for ovarian suppression
o Encouraging evidence from trials on women having chemotherapy for breast cancer
o No clear evidence on other cancers – can try empirically

• Oocyte / embryo cryopreservation
o Reproductive autonomy vs freeze-thaw survival

• Social egg freezing/ anticipation of age-related decline in fertility

4th Year GOSH (23 decks)

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