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REPRO > Infertility > Flashcards

Infertility Flashcards

1
Q

what is a basic definition of infertility

A

the inability of a couple to conceive within 12 months without the use of contraception

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2
Q

what % of couples are able to conceive without problem

A

for those <40yrs:
80% will conceive within 1 year of trying
half of those who do not in the first year will in the second

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3
Q

how many couples experience problems with fertility

A

1 in 7

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4
Q

when should infertility be investigated

A

if after 1 year of trying there is no pregnancy

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5
Q

when should you potentially investigate fertility sooner

A 
if there's a problem e.g.
period irregularity
past medical history
testicular problems
abnormal test results
HIV/Hep B
anxiety

age
<36 yrs after 1 year
35-45 years after 6 months
>45 yrs little can be offered

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6
Q

what are the three main queries when it comes to infertility

A

are there eggs available?
is there sperm available?
can they meet?

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7
Q

what should be covered in a female history for infertility

A 
duration of infertility 
previous contraception
fertility in previous relationships
previous pregnancies/complications
menstrual history
medical/surgical history
sexual history
previous investigations
psychological assessment
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8
Q

what should be covered in a female examination for infertility

A 
weight
height
BMI (kg/m2)
fat and hair distribution
galactorrhoea
abdominal examinaton
pelvic examination
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9
Q

what are the implications of a higher BMI >30 on fertility/pregnancy

A

higher miscarriage rate
lower success of fertility treatment
higher medical complications e.g. HBP, diabetes

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10
Q

what does your BMI need to be to qualify for NHS fertility treatment

A

<30

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11
Q

what initial tests should be done for women first presenting with infertility problems

A

prolactin levels - prolactinaemia - if >1000 assess pituitary gland

androgen levels

  • testosterone (T)
  • androstendione
  • dehydroepiandrosterone (DHA)
  • dehydroepiandrosterone sulphate (DHAS)
  • 17-OH progesterone
  • Sex hormone binding globulin (SHBG)
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12
Q

how can hirsutism be measured clinically

A

look for hirsutism

ferriman gallwey score - from hair distribution on:
upper lips, chin, anterior chest, inner thigh, back

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13
Q

how is the ferriman gallwey score interpreted

A

Score <8 – no hirsutism
8-16 – mild
17-25 - moderate
>25 – severe

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14
Q

what are clinical signs of androgen excess

A

hirsutism
galactorrhoea
acanthosis nigricans

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15
Q

what should be looked for in a pelvic exam

A 
masses/fibroids
pelvic distortion
fixed retroversion
tenderness
cervical abnormality
vaginal septum
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16
Q

what are the complications of fibroids

A

pressure symptoms
period problems
infertility

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17
Q

what are the different kinds of fibroids

A

subserosal - outwith the lining of the muscles and uterine cavity - pressure symptoms, press on bladder, pain

intramural - if >1/2cm can interfere with implantation

submucosal - can interfere with implantation

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18
Q

what should be covered in a male history for infertility

A

Previous fertility
Medical history (mumps, testicular descent)
Surgical history
Occupational history
Sexual history (STD)
Previous investigations and treatment (varicocoele repair, vasectomy)
loss of body hair/less frequent shaving (less testosterone)

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19
Q

what should be covered in a male examination for infertility

A 
weight
height
BMI (kg/m2)
fat and hair distribution (hypoandrogenism)
abdominal and inguinal examination
genital examination
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20
Q

how can the male partners BMI affect fertility

A

high BMI can have a negative influence of spermatogenesis

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21
Q

what can examination of the epididymis show

A

epididymitis

STDs - chlamydia, gonorrhoea, NSTD

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22
Q

what can examination of testicular size show

A

klinefelter syndrome

hyperspermia

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23
Q

what can examination of the vas deferens show

A

possible CF - mutations and congenital bilateral absence of the vas deferens

NB if azoospermatic - indication to test for CF

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24
Q

what can examination of the testes show

A

testicular tumours

testicular maldescent

25
Q

what is varicocoele and where is it more common

A

abnormla dilatio anf torsion of the veins in the scrotum

- more common on the left, anatomical drainage different as the they drain to the left renal vein instead of the IVC

26
Q

what can examination of the penis show

A

hypospadias

27
Q

how do you test for the availability of eggs

A

test serum progesterone in the mid-luteal phase of the cycle - day 21-28 to confirm ovulation if they have regular menstrual cycles

if irregular cycles - blood tests to measure serum gonadotrophins follicle stimulating hormone (FSH) and luteinising hormone (LH)

28
Q

how do you test for the availability of sperm

A

computerised semen analysis

29
Q 
according to WHO what are the reference vakues of: 
semen volume
sperm concetration
total sperm number
progressive motility
total motility
morphologically normal
A 
1.5ml
15 million/ml
39 million
32%
40%
4%
30
Q

what are the baseline investigations for a female partner investigating infertility

A

rubella immunity
chlamydia
TSH
if periods regular - mid-luteal progesterone (7 days prior to expected period)
if periods irregular - day 1-5 FSH, LH, PRL, TSH, testosterone

31
Q

what are the baseline investigation for a male partner investigating infertility

A

semen analysis

32
Q

what investigations can be done at the fertility clinical

A 
pelvic ultrasounds
physical exam
further investigations
semen analysis repeat if required
tubal patency test
33
Q

what is a HyCoSy and what is it used for

A

hysterosalpingo-contrast-sonography
small catheter though cervix then dye injected through

looks for patent tubes

34
Q

what is laparoscopy used for

A

can assess tubal potency
diagnostic and therapautic to treat endometriosis
preferred for women with a higher tubal factor

35
Q

what are the riss of laparotomy

A

risk of injury to bowel, bladder, ureter, thromboembolism

36
Q

what is the difference between primary and secondary infertility

A

primary is couples who are struggling to conceive after 1 year with no previous pregnancies

secondary is couples who are struggling to convince after 1 year with at least one previous pregnancy i.e. were able to conceive before but not unable to

37
Q

from most common to least common, what are the causes of primary infertility

A

ovulation problems
male - sperm problems
unexplained
tubal

38
Q

from most common to least common, what are the causes of secondary infertility

A

tubal
ovulation problems
unexplained
male - sperm problems

39
Q

what is polycystic ovary syndrome

A

set of symptoms due to elevated androgens in females

40
Q

how can polycystic ovary syndrome be diagnosed

A

must beet 2 of the 3 criteria:

  1. androgen excess (clinical hirsutism, biochemical testosterone)
  2. infrequent periods (anovulation)
  3. polycystic ovaries (seen on underground
41
Q

what defines a polycystic ovary

A

more than 12 follicles in one ovary

42
Q

what are the three groups of causes for ovulatory disorders

A
  1. hypothalamic pituitary failure
  2. hypo-pituitary-ovarian failure
  3. ovarian failure
43
Q

what is the treatment for ovulatory disorders

A

treat the underlying cause
weight loss/gain (BMI >18and <30)
ovulation induction

44
Q

what are the three drugs used for ovulation induction

A

clomiphene (first line)
gonadotrophins
GnRH

45
Q

what is clomiphene and how is it given

A

selective oestrogen receptor modulator
given 50mg-150mg day 2-6 of the cycle
if amenorrhoea - progestogen priming

NB does usually kept as low as possible to encourage only mono follicular development (higher % of conception)

46
Q

how and why is clomiphene monitored

A

follicle scanning occurs in the 1st cycle

needed as 15% require a dose adjustment

47
Q

what are the side effects of clomiphene

A

vasomotor

visual

48
Q

how long can clomiphene be given for

A

6 cycles

49
Q

when might gonadotrophin therapy be used

A

when no ovulation with clomiphene or ovulation but no pregnancy

50
Q

how is gonadotrophin therapy given

A

FSH injection up to 3-6 cycles

51
Q

what can be done if there is a tubal factor or endometriosis affecting fertility

A

some surgical or medical treatment for endometriosis and fibroids

consider IVF

52
Q

what should a women with hydrasalpinges be offered before IVF and why

A

salpingectomy - fluid filled blocked tubes may cause further problems such as ectopic pregnancy

53
Q

what treatment for infertility can males use

A 
urologist appointment if appropriate 
IVF/ICSI
intra-uterine insemination
surgery (vasectomy reversal, surgical sperm retrieval)
donor insemination
54
Q

what is azoospermia

A

when semen contains no sperm

55
Q

what are the types of azoospermia

A

testicular

  • normogonadotrophic
  • hypogonadotrophic
  • hypergonadotrophic

post-testicular

  • iatrogenic
  • congenital
  • infective
56
Q

what are the investigations for azoospermia

A

history
examination
FSH, LH, testosterone, karyotype, PRL
CF screen

57
Q

what is a possible treatment for azoospermia

A

surgical sperm retrieval

  • micro-epididymal sperm aspiration
  • testicular sperm extraction
58
Q

what are some options for sexual problems that lead to infertility

A

psychosexual counselling - onward referral

artificial insemination - times at home, intra-uterine at clinic

59
Q

what is the best course of action in treating unexplained infertility

A

IVF

don’t offer clomiphene

REPRO (44 decks)

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