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Obs & Gynae > Infertility > Flashcards

Infertility Flashcards

1
Q

What is infertility

A

An inability to conceive after 12 months of regular intercourse (2-3 days)
Primary = if never conceived before

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2
Q

When should you investigate

A

After 1 year of trying

Earlier if known issue

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3
Q

What are known issues / reasons for early referral

A 
Age >35
Amenorrhoea / PCOS 
Previous pelvic surgery or on genitalia 
Previous STI - inc HIV / hep B 
Abnormal genital exam
Varicocele 
Systemic illness
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4
Q

When are you most fertile

A

Day 10-17 of cycle

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5
Q

What happens during your cycle

A

Luteal phase after ovulation = 14 days constant
Follicular = average 14
Ovulate on last day of follicle

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6
Q

When do you measure progesterone levels to see if ovulated

When do you ovulate

A

7 days prior to next period - usually day 21

14 days prior to next period

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7
Q

What can cause infertility

A 
Ovulatory
Tubal factor
Uterine / endometrial abnormality
Sexual problem
Azoospermia 
Unexplained
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8
Q

What causes ovulatory disorder

A 
Any cause 2 amenorrhoea
Exercise / weight loss
Hypogonadotrophic hypogonadism - hypothalamus / pituitary
PCOS
Ovarian failure
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9
Q

Wha causes tubal issue s

A 
PID
Previous ectopic
Previous surgery
Sterile 
Endometriosis
Fibroid compressing
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10
Q

What is unexplained

A

Test to see if eggs
Test to see if sperm
Can they meet and implant
If all fine= unexplained

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11
Q

What do you look in examination of the male

A 
BMI
Features of increased androgen
- Increased fat 
- Decreased hair
Abdo and inguinal exam
STI
Testicular size
Varicoccele
Vas deferens
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12
Q

What do you look for in female examination

A 
BMI
Fat and hair distribution 
Hirsutism
Galactorrhoea
Abdo and pelvic exam 
Acanthosis nigrican
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13
Q

What does hirsutism suggest

A

PCOS = most common
Androgen excess
Adrenal hyperplasia
Cushings

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14
Q

What does aconthosis nigrican suggest

A

Androgen excess

Insulin resistance

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15
Q

When does fertility decrease

A

Age
Chemo / RT
Can preserve embryos by freezing

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16
Q

What are 1st line investigations do you do in male and female

A

Computerised semen analysis

Mid literal progesterone or FSH / LH / testosterone if irregular to see if ovulating

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17
Q

What other female investigations are done prior to clinic

A 
BMI - if low anovulation? if high PCOS? 
Pelvic and breast exam
C+G
Rubella
TFT / prolactin 
Pelvic USS to look for structural
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18
Q

What do you do at clinic

A

Tubal potency test for blockage
HSG or HyCOSy - hysterosalpingography
Laparoscopy - Dx and can treat

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19
Q

How do you treat infertility / general advice

A 
Rx underlying condition e.g. PID 
Regular intercourse 2-3 days
Smoking and drinking advice
Aim BIM 
Folic acid 400mg
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20
Q

What do you do for ovulatory disorder

A

Clomifene = 1st line
Gonadotrophin
Metformin
FSH Injection

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21
Q

What is Clomifene

A

SERM
Triggers FSH and LH release regularly
Scan to see 1 dominant follicle

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22
Q

What are risks of clomifene

A

Multiple pregnancy
Ovarian cancer
Hyperstimulation
Can only use for 6 cycles

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23
Q

When do you use gonadotrophin

A

No ovulation after 6 cycles

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24
Q

What is metformin helpful in

A

Underlying insulin resistance

May be used in addition to clomifene as increases effectiveness if resistant

25
Q

What do you do for tubal factor

A

Surgery to remove or bypass tube
- Risk of ectopic
IVF

26
Q

What is the only option for unexplained

A

IVF

NO ovarian stimulation

27
Q

What is criteria for IVF

A

<42
BMI <30
Non smoker
No children

28
Q

What are the symptoms of ovarian hyper stimulation and how do you treat

  • More common with gonadotrophin / hCG Rx over clomifene
A 
Abdo pain
Bloating
N+V
Diarrhoea 
Hypotension
If severe 
Ascites 
Oliguria 
Raised haematocrit 
VTE / ARDS = critical

Due to cystic enlargement so more at risk if have PCOS

Fluid resus + VTE prophylaxis

29
Q

What is azoospermia

A

No sperm in ejaculate

30
Q

What are testicular causes of azoospermia

A

Hypogonadotrophic hypogonadism

Klienfelter syndrome

31
Q

What does Klienflter present with

A 
XXY 
Hypogonadism
Low testosterone
Small testicles
Azoospermia
32
Q

What are post-testicular causes

A 
Radiation
Congenital
Infective - mumps. STI
Absence of vas deferends
Vasectomy
33
Q

What puts you at risk of azoospermia

A

Smoking
Exposure to heat and chemical
Anabolic steroid

34
Q

What investigations should be done

A 
FSH / LH
Testosterone
Prolactin
Karyotype
CF screem
Serum analysis
35
Q

How do you treat Klienfelter

A

Testosterone injection

36
Q

How do you treat azoospermia

A 
Surgical sperm retrieval
Intra-uterine insemination
Reverse vasectomy
Donor insemination
IVF
37
Q

What is PCOS

A

Syndrome of ovarian dysfunction
Features of hyperandrogegism and PCO
Causes 80% of fertility issues

38
Q

What causes PCOS

A

Disorder LH production
Insulin resistance so increased levels
Increased androgen disrupts folliculogenesis

RF

  • Obesity
  • FH
  • Ethnicity
39
Q

What criteria used to Dx

A

Rotterdam

Require 2/3

40
Q

What is Rotterdam criteria

A

PCO
Anovulation or oligo
Androgenic symptoms or elevated total or free serum testosterone (low SHBG)

41
Q

What are symptoms of increased androgen

A 
Hirsutism
Acne 
Deep voice
Enlarged clit 
Cushionoid
Excess testosterone

Being on the COCP can hide these symptoms

42
Q

What are other symptoms

A 
Obesity
Infertility
Irregular cycle 
Can have heavy periods
Plenty oestrogen but also high androgen
Insulin resistance = DM (insulin promotes release of more androgens) 
CVS disease 
Aconthosis nigrican
Chronic pelvic pain
Depression
43
Q

How do you Dx / investigate at GP

A

Basic obs, BM, urine dip
Bloods - FBC, U+E, LFT, TFT, total testeroterone or sex hormone binding

Further 
Mid literal progesterone 
Hormonal profile 
Pelvic / transvaginal USS
Check for impaired glucose tolerance
Full infertility work up if want to conceive
44
Q

When do you start on induction therapy

A

If all hormones are fine

45
Q

What is hormonal profile

A 
LH - raised
LH / FSH ratio = raised 
FSH
TSH 
Prolactin
Testosterone = can be raised 
Oestrogen
46
Q

What are general measures

A

Weight loss = 1st step in increasing fertility
Exercise
Stop smoking
Monitor BP / lipid
Screen for DM every 3-5 years
Endometrial cancer risk - mineral coil or COCP to get regular bleed

47
Q

What is step wise approach for fertility

A 
Clomifene = 1st line 
Metfomrin = increase insulin resistance 
Gonaotropin 
- FSH or LH injection when follicle grown
IVF = last resort
48
Q

What does clomifene do

A

Binds to oestrogen receptor in pituitary

Trigger release of FSH and LH

49
Q

What helps with androgen symptoms as anti-androgen / Hirstusim

A 
Combined OCP
Facial hair cream
Metformin 
Cyproterone acetate / spironolactone = anti-androgen but must be on contraception 
Co-cyprindol - regulate menstruation
50
Q

What do you give for endometrial protection as

anovulation increases risk / regulate menstruation

A

COCP
- Want 3-4 bleeds
Progestogen
Mirena IUS

51
Q

What are surgical options

A

Drilling

52
Q

What are complications of PCOS

A 
DM type 2
Obesity 
Higher CVD risk
Higher VTE risk
Endometrial hyperplasia 
OSA
Infertility
Miscarriage
53
Q

What is PCO

A

> 10 cyst
Not technically cyst - follicles that start to develop then arrest
Hypo-echoic
or volume >12

54
Q

What must you exclude

A 
Other causes of hyperandrogegism 
Adrenal or ovarian tumour 
Adrenal hyperplasia
Cushing
Pituitary tumour
55
Q

What is metformin useful for

A

Increasing effectiveness of clomifene
Reduce gestational DM and miscarriage
Reduce Hirsutism

56
Q

What is risk of anovulation in PCOS

A

No CL so no progesterone
No uterine bled and shed of lining
Increased risk of endometrial hyperplasia
Get irregular breakthrough bleed

57
Q

What must you exclude if rapid onset hirsutism and very high testoerstoerne

A

testosterone secreting tumour

58
Q

If abnormal prolactin

A

MRI head for prolactinoma

Obs & Gynae (23 decks)

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