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Obstetrics & Gynaecology > Infertility > Flashcards

Infertility Flashcards

1
Q

After how many months of unprotected SI, without conception, is a couple deemed infertile?

A

24 months

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2
Q

After how may month of unprotected SI, without conception, is it before a couple may be referred to fertility services?

A

12 months

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3
Q

What is primary infertility?

A

A couple have never conceived before

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4
Q

What is secondary infertility?

A

A couple have conceived previously

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5
Q

What are the four broad, over-arching, causes of infertility?

A
  1. Female factor
  2. Male factor
  3. Mixed
  4. Unexplained
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6
Q

What are the 3 types of female factor causes of infertility?

A
  1. Anovulation
  2. Obstruction to fertilisation
  3. Obstruction to implantation
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7
Q

What are the causes of anovulation?

A
  1. Hypogonadotrophic hypogonadism
  2. Hyperprolactinaemia
  3. PCOS
  4. Hypo/hyper-thyroidism
  5. Premature ovarian failure
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8
Q

How may fertilisation be obstructed?

A

By tubal blockage, through either PID, endometriosis or adhesions from previous surgery

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9
Q

How may implantation be obstructed?

A

Fibroids

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10
Q

How may the causes of male factor infertility be categorized?

A
  1. Pre-testicular
  2. Testicular
  3. Post-testicular
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11
Q

What are the pre-testicular causes of infertility?

A
  1. Smoking
  2. Drugs that decrease FSH
  3. Secondary hypogonadism (hypogonadotrophic hypogonadism)
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12
Q

What drug may decrease FSH?

A

Phenytoin

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13
Q

How may causes of hypogonadotrophic hypogonadism be categorised?

A
  1. Hypothalamic causes

2. Hypopituitarism causes

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14
Q

What are the hypothalamic causes of hypogonadotrophic hypongonadism?

A
  1. Obesity

2. Kallmann syndrome

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15
Q

What are the hypopituitarsim causes of hypogonadotrophic hypogonadism?

A
  1. Pituitary adenoma
  2. (Rarely) other brain tumours - e.g. menigioma, glioma, mets, craniopharyngioma
  3. Infection of the brain or gland itself
  4. Infiltration - e.g. neurosarcoidosis
  5. Inflammation - e.g. autoimmune attack
  6. Empty sellae syndrome
  7. Pituitary apoplexy (haemorrhage or infarction)
  8. Radiation
  9. TBI
  10. Subarachnoid haemorrhage
  11. Surgery
  12. Congenital
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16
Q

What are the testicular causes of male infertility?

A
  1. Maldescention
  2. Testicular cancer
  3. Trauma
  4. Radiotherapy
  5. Drugs that decrease sperm motility
  6. Genetic factors
  7. Primary hypogonadism
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17
Q

Which drugs can decrease sperm motility?

A

Sulfasalazine and nitrofurantoin

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18
Q

What are the causes of primary hypogonadism?

A
  1. Klinefelter’s
  2. Mumps
  3. Varicocelle
  4. Anabolic steroids
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19
Q

What are the post-testicular causes of male factor infertility?

A
  1. Obstruction of the vas deferens
  2. CAVD
  3. Infection - e.g. prostatitis
  4. Ejaculatory duct dysfunction
  5. Retrograde ejaculation
  6. Impotence
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20
Q

When can referral to infertility services be expedited?

A
  1. > /=36 y/o
  2. Known clinical cause of infertility (e.g. Turner’s)
  3. Treatment is planned that may cause infertility, e.g. cancer treatment
  4. Patient(s) known to have chronic infection, e.g. HIV/hep that requires risk-reduction infertility treatment
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21
Q

What is the classic triad of congenital rubella syndrome?

A
  1. Sensioneural deafness
  2. Eye abnormalities - esp. cataracts
  3. CHD - esp. PDA
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22
Q

What is the lower limit of normal for semen volume?

A

1.5ml

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23
Q

What is the lower limit of normal for semen pH?

A

7.2

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24
Q

What is the lower limit of normal for sperm concentration in semen?

A

15 million/ml

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25
Q

What is the lower limit of normal for total number of sperm in a semen sample?

A

39 million/ejaculate

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26
Q

What is the lower limit of normal for total sperm motility in a semen sample?

A

40% motile (progressive and non-progressive - A+B)

32% progressively motile (A)

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27
Q

What is the lower limit of normal for sperm vitality in a semen sample?

A

58% living

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28
Q

What is the lower limit of normal for sperm morphology is a semen sample?

A

4% normal forms

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29
Q

What factors can effect sperm quality?

A
  1. Temp
  2. Smoking
  3. Obesity
  4. Excessive alcohol consumption
  5. Prescription drugs
30
Q

How may anovulatory disorders be classified?

A

Group 1 = hypothalamic-pituitary failure - i.e. hypothalamic amenorrhoea or hypogonadotrophic hypogonadism

Group II = hypothalamic-pituitary-ovarian dysfunction - i.e. mostly PCOS

Group III = ovarian failure

31
Q

How do you manage group I anovulatory women?

A

Offer pulsatile GnRH adminstration

For women with hyperprolactinaemia, offer bromocriptine

32
Q

How do you manage group II anovulatory women?

A

Advise WL

Then offer Clomid, metoformin, or a combination of the two

33
Q

What is the generic name for Clomid?

A

Clomifene

34
Q

What type of drug is Clomid?

A

An anti-oestrogen - a SERM, i.e. a selective estrogen receptor modulator

35
Q

How does Clomid work?

A

It inhibits estrogen receptors in the hypothalamus, and thus inhibits negative feedback by oestrogen, so LH/FSH are continually synthesized and release by the ant pit, allowing FSH to continually stimulate the follicles

36
Q

What are the risks of Clomid (ovulation induction)?

A
  1. OHSS

2. Multiple pregnancy

37
Q

What procedures should be offered to women with proximal tubal obstruction (where there is no MFI)?

A

Selective salpingography + either tubal catherterisation or hysteroscopic tubal cannulation

38
Q

In whom may IUI be considered?

A
  1. Those for whom vaginal intercourse would be difficult (e.g. psychosexual problems)
  2. Where the male partner is HIV +ve (post-sperm washing)
  3. Same-sex relationships
39
Q

How many cycles of IUI may be offered?

A

Up to 12. If conception has not occurred by 6, consider investigating tubal patency

40
Q

What is the cumulative pregnancy rate in IUI?

A

> 75%

41
Q

What AMH level is considered to give a low response?

A

= 5.4pmol/l

42
Q

What AMH level is considered to give a high response?

A

> /= 25.0pmol/l

43
Q

Who might have a high AMH level?

A

Women at the start of their reproductive lives, or women with PCOS

44
Q

When can an AMH level be taken, and why?

A

At any point during a woman’s cycle - because AMH is only produced by small follicles (<8mm), not developing follicles, therefore there is no monthly fluctuation

45
Q

On the basis of a ‘normal’ AMH result, what ovarain stimulation protocol would a women be offered?

A

‘Standard’ long protocol

46
Q

On the basis of a ‘high’ AMH result, what ovarian stimulation protocol would a woman be offered?

A

Cetrotide protocol

47
Q

On the basis of a ‘low’ AMH result, what ovarian stimulation protocol would a woman be offered?

A

Flare protcol

48
Q

What agents may be used in downregulation?

A

GnRH agonists or antagonists

49
Q

Name a GnRH agonist:

A

Buserelin

50
Q

Name a GnRH antagonist:

A

Cetrotide (used when at risk of over-responding. When anatagonist used for downregulation, ovulation trigger must be GnRH agonist, rather than hCG)

51
Q

What are the signs of downregulation looked for on a baseline scan?

A
  1. Inactive ovaries

2. Thin endometrial lining

52
Q

At the baseline scan, what proportion of women will not be ready to proceed to FSH stimulation, and why may they not be ready?

A

10-15% of women will not be ready at the first baseline scan. This may be due to either:

  1. Inadequate downregulation
  2. Presence of an ovarian cyst
53
Q

Which brand/s are recombinant FSH?

A

Gonal F and Bemfola

54
Q

Which brand/s are urinary-derived FSH?

A

Menopur

55
Q

Whom should Menopur be considered for, and why?

A

Women with hypogonadotrophic hypogonadism, or women whom have undergone the ultra-long protocol (e.g. due to endometriosis). This is because they will likely be depleted in LH AND FSH, and this a combined preparation (rather than just FSH) may be useful

56
Q

When is the first action scan?

A

On day 8 of FSH stimulation

57
Q

At what rate do ovarian follicles grow each day?

A

1-1.5mm

58
Q

What is required of the follicles seen on the action scan in order for oocyte retrieval to be scheduled?

A

2 follicles, >/=18mm

59
Q

Upon the first action scan, what proportion of women will be considered to be showing a ‘slow response’ and thus need re-scanning 48-72 hours later?

A

40-50%

60
Q

What proportion of women undergoing FSH stimulation will be considered to be showing a ‘poor response’, and thus in need of an increased dose of FSH, or for whom the cycle will need to be abandoned?

A

8%

61
Q

How many hours before oocyte retrieval should hCG be administered?

A

36 hours

62
Q

What are the indications for insemination with donor sperm?

A
  1. Obstructive azoospermia
  2. Non-obstructive azoospermia
  3. Deficits in semen quality but couple do not wish to undergo ICSI
  4. Risk of tranmsitting genetic disorder to offspring
  5. Risk of transmitting infectious disease to offspring or partner
63
Q

What are the indications for the use of donor eggs?

A
  1. Increasing age, low reserve or quality
  2. Premature ovarian failure
  3. Ovarian dysgenesis - e.g. Turner’s syndrome
  4. Bilateral oophorectomy
  5. Ovarian failure following chemo/radiation
  6. Risk of transmitting genetic disorder to offspring
64
Q

What are the complications of infertility treatment?

A

Downregulation = menopausal Sx

Ovarian stimulation drugs = OHSS

Oocyte retrieval = abscess, perforation, ovarian haemorrhage, DVT, failure to retrieve eggs, pain, anaphylaxis

ET = dailure of implantation

IVF = multiple pregnancy

65
Q

Which women are at greater risk of a pelvic abscess as a result of oocyte retrieval?

A

Those with either:

  1. Endometriomas
  2. Hydrosalpinx
66
Q

What are the specific risks of ICSI?

A
  1. Epigenetic defects, esp. Beckwith-Wiedemann
  2. Congential defects - esp. urogenital
  3. Slight increase in miscarriage
  4. MFI of father could be inherited by son
  5. If MFI is caused by a genetic condition, the genetic condition could be inherited by the offspring, e.g. CF
67
Q

What are the RFs for OHSS?

A
  1. PCOS
  2. <30y/o
  3. PMHx of PCOS
  4. High antral follicle count
  5. High AMH
68
Q

Which is more common, early or late OHSS?

A

Early

69
Q

When does early OHSS present?

A

Within 7 days of hCG injection

70
Q

When does late OHSS present?

A

> 10 days from hCG injection

Obstetrics & Gynaecology (14 decks)

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