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Systems: Reproduction AB > Infertility > Flashcards

Infertility Flashcards

1
Q

What is infertility?

A

It is defined as inability of a couple to conceive after 12 months of regular intercourse without use of contraception.

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2
Q

How common is infertility?

A

1 in 7 couples report infertility problems

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3
Q

What is the chance of conception?

A

Over 80% of couples in the general population will conceive within 1year if

  • Women <40 years old
  • Do not use contraception
  • Having regular sexual intercourse

Of those who do not conceive in the first year, about half will do so in the second year (cumulative pregnancy rate over90%).

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4
Q

When should you investigate for infertility?

A

If haven’t conceived within 1 year despite actively trying

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5
Q

What are the 4 questions surrounding the cause of fertility problems?

A
  • Are eggs available?
  • Are sperm available?
  • Can they meet?
  • Can embryo implant ?
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6
Q

What should you ask about when taking a female’s history?

A
  • Duration of infertility
  • Previous contraception
  • Fertility in previous relationships
  • Previous pregnancies and complications
  • Menstrual history
  • Medical and surgical history
  • Sexual history
  • Previous investigations
  • Psychological assessment
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7
Q

What examination should a female undergo?

A
  • Weight
  • Height
  • BMI (kg/m2)
  • Fat and hair distribution
  • Galactorrhoea
  • Abdominal examination
  • Pelvic examination
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8
Q

What is hirsutism caused by?

A

Andorgen excess

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9
Q

What scoring system is used for androgen excess?

A

Ferriman Gallwey score

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10
Q

What biochemical measurents are carried out in androgen excess?

A
  • Testosterone (T)
  • Dehydroepiandrosterone sulphate (DHEAS) if is greater than 700 mcg/dL (18.9 micromol/L) adrenal computed tomography (CT) is recommended to look for an androgen-secreting adrenal tumor
  • 17-OH Progesterone
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11
Q

Name a skin sign of androgen excess.

A

Acanthosis nigricans

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12
Q

What is looked for on pelvic examination of a female?

A
  • Masses
  • Pelvic distortion
  • Tenderness
  • Vaginal septum
  • Cervical abnormalities
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13
Q

How can fibroids present?

A
  • Pressure symptoms
  • Period problems
  • Infertility
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14
Q

What baseline investigations are done for the female?

A
  • Rubella immunity,
  • Chlamydia
  • TSH
  • If periods are regular: Mid luteal progesterone ( 7 days prior to expected period);
  • If periods are irregular please do day 1-5 FSH, LH, PRL, TSH, testosterone
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15
Q

What baseline investigation is carried out on the male?

A

Semen analysis

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16
Q

What investigations are carried out at the fertility clinic?

A
  • Pelvic Ultrasound
  • Physical examination
  • Testing for ovulation
  • Semen analysis repeat if required
  • Tubal patency test
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17
Q

What should women who are concerned about their fertility be asked about?

A

Frequency and regularity of menstrual cycles

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18
Q

If a women is having regular menstrual cycles, what is unlikely to be the cause of infertility?

A

Ovulation

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19
Q

How is ovulation confirmed?

A

A blood test to measure serum progesterone in the mid-luteal phase of their cycle (day21 of a 28‑day cycle) to confirm ovulation even if they have regular menstrual cycles

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20
Q

What should women who have prolonged irregular menstrual cycles be offered?

A
  • A blood test to measure serum progesterone.
  • Depending upon the timing of menstrual periods, this test may need to be conducted later in the cycle (for example day28 of a 35‑day cycle) and repeated weekly thereafter until the next menstrual cycle starts
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21
Q

What should women with irregular menstrual cycles be offered?

A

A blood test to measure serum gonadotrophins (FSH and LH )

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22
Q

How are tubal and uterine abnormalities screened for?

A
  • Hysterosalpingography

- HyCoSy

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23
Q

Who should be offered hysterosalpinography?

A

Women who are not known to have comorbidities (such as pelvic inflammatory disease, previous ectopic pregnancy or endometriosis)

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24
Q

Why is a hysterosalpingogram carried out?

A

To screen for tubal occlusion because this is a reliable test for ruling out tubal occlusion, and it is less invasive and makes more efficient use of resources than laparoscopy.

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25
Q

What is important to ask about in the male history?

A

Developmental (Testicular descent, change in shaving frequency, loss of body hair )

Infections (mumps , STIs)

Surgical (varicocele repair, vasectomy)

Previous fertility

Environmental (alcohol, smoking, anabolic steroids, chemotherapy, radiation, drug use)

Sexual history (libido, frequency of intercourse, previous fertility assessment)

Any chronic illness

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26
Q

What is carried out for examination of the male?

A
  • Weight
  • Height
  • BMI (kg/m2)
  • Fat and hair distribution (hypoandrogenism)
  • Abdominal and inguinal examination
  • Genital examination (epididymis, testes, vas deferens, varicocele)
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27
Q

What is the most common cause of epididymitis?

A

STI

  • Chlamydia
  • Gonorrhoea
28
Q

What is a varicocele?

A
  • A dilatation of the pampiniform plexus of the spermatic veins in the scrotum.
  • Most men with varicocele and presumptive infertility have abnormal semen parameters, including low sperm concentration and abnormal
29
Q

Why should men with varicocele not be offered surgery as fertility treatment?

A

Does not improve fertility rates

30
Q

What is one of the most common causes of primary hypogonadism (impaired spermatogenesis and testosterone deficiency)?

A

Klinefelter syndrome

31
Q

What is Klinefelter syndrome characterised by?

A
  • Sex chromosome aneuploidy, with an extra X (XXY) chromosome being the most frequent.
  • These patients often have very small testes and almost always have azoospermia
32
Q

What is the incidence of Klinefelter syndrome?

A
  • 1 out of 500 to 700 phenotypic males

- Up to 10 to 15 percent of infertile men with azoospermia

33
Q

What can lead to congenital bilateral absence of the vas deferens?

A

Cystic fibrosis mutations

34
Q

What are the lower lab levels for sperm analysis?

A
  • Semen volume (1.5ml)
  • Sperm concentration (15 million/ml)
  • Total sperm number (39 million)
  • Progressive motility (32%)
  • Total motility (40%)
  • Morphologically normal (4%)
35
Q

When should infertility be referred to clinic before 1 year of trying?

A
  • Period irregularity
  • Past medical history
  • Testicular problems
  • Abnormal tests
  • HIV/Hep B
  • Anxiety

Age

  • 35-45 (after 6 months)
  • > 45 years little can be offered
36
Q

What are the 3 groups of ovulatory disorders?

A

Group 1
-Hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism).

Group 2
-Hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome).

Group 3
-Ovarian failure (POI)

37
Q

What advise should women with group 1 ovulation disorders be given?

A

They can improve their chance of regular ovulation, conception and an uncomplicated pregnancy by:
-Increasing their body weight if they have a BMI of less than19 and/or
moderating their exercise levels if they undertake high levels of exercise.

38
Q

What medication should women with group 1 ovulatory disorders be given?

A

Pulsatile administration of gonadotrophin-releasing hormone or gonadotrophins with luteinising hormone activity to induce ovulation.

39
Q

What is the triad of PCOS?

A
  • Androgen excess
  • Infrequent periods
  • Polycystic ovaries
40
Q

How is PCOS diagnosed?

A
  • Clinical (hirsutism)
  • Biochemical (testosterone levels)
  • Anovulation
  • Ultrasound
41
Q

What is the general management for fertility issues related to ovulatory disorders?

A
  • Treat underlying cause
  • Weight loss/gain
  • BMI >18 and <35
  • Ovulation Induction by clomifene and gonadotrophins
42
Q

How does clomifene work?

A

Blocks oestrogen receptors in the anterior pituitary, leading to increased secretion of FSH through loss of negative feedback

43
Q

What is clomifene?

A

A selective oestrogen receptor modulator

44
Q

What are the possible side effects of clomifene?

A
  • Vasomotor

- Visual

45
Q

How is clomifene use monitored?

A
  • Follicle scanning in 1st cycle

- 15% will require a dose adjustment

46
Q

What is the dose of clomifene?

A

50mg-150mg day 2-6

47
Q

When are gonadotrophins used to treat infertility?

A
  • No ovulation with Clomifene

- Ovulation but no pregnancy

48
Q

What gonadotrophin therapy can be used?

A
  • FSH by injection

- Up to 3-6 cycles

49
Q

What should women with hydrosalpinges be offered?

A

A salpingectomy, preferably by laparoscopy, before IVF treatment because this improves the chance of a live birth.

50
Q

What treatments are available to address male factors?

A
  • Urologist referral if appropriate
  • IVF/ICSI
  • Intra-uterine insemination
  • Reversal of vasectomy
  • Surgical sperm retrieval
  • Donor insemination
51
Q

What are the post testicular causes of azoospermia?

A
  • Iatrogenic
  • Congenital
  • Infective
52
Q

How should azoospermia be investigated?

A
  • History
  • Examination
  • FSH, LH, Testosterone, Karyotype, PRL
  • CF screen
53
Q

What should women with unexplained fertility be told?

A
  • Inform women with unexplained infertility that clomifene citrate as a stand-alone treatment does not increase the chances of a pregnancy or a live birth.
  • Advise women with unexplained infertility who are having regular unprotected sexual intercourse to try to conceive for a total of 2years (this can include up to 1year before their fertility investigations) before IVF will be considered.
54
Q

What should women with unexplained infertility be offered?

A

IVF treatment

55
Q

What should women with unexplained infertility not be offered?

A

Ovarian stimulation agents such as clomifene

56
Q

Briefly describe IVF.

A
  • Eggs harvested from ovary
  • Eggs fertilised in the lab with sperm
  • Embryos undergo a number of cell divisions
  • Embryos transferred to the womb
57
Q

What is intracytoplasmic sperm injection?

A
  • Injection of mature eggs with single sperm

- Incubation overnight

58
Q

What changes in society are leading to fertility issues?

A
  • Single women
  • Same sex couples
  • Older women
  • Obesity
59
Q

What is primary infertility?

A

Infertility in someone who has never conceived before

60
Q

How do you define irregular periods?

A

Periods which have variation of around 7 or more days per month

61
Q

What criteria is used to diagnose PCOS?

A

Rotterdam criteria

62
Q

What is first line fertility treatment in someone with PCOS?

A

Weight loss until normal BMI

63
Q

What can cause tubal block in a female?

A
  • Inflammatory disease
  • STI
  • Sterilisation
  • Endometriosis
64
Q

What is azoospermia?

A

Ejaculate with absence of sperm

65
Q

What is unexplained infertility?

A

Unexplained infertility is when there is infertility without obvious disturbance to the eggs, sperm or tubes

66
Q

How common is unexplained infertility?

A

In 1 in 3 couples who have infertility it is unexplained

Systems: Reproduction AB (35 decks)

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