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Year 3 - Reproduction > Infertility > Flashcards

Infertility Flashcards

1
Q

What ratio of couples have infertility problems?

A

1 in 7

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2
Q

What is the definition of 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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3
Q

What percentage of couples in the general population will conceive within one year?

What conditions are required for these figures?

A

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

1) The woman is aged under 40years
2) They do not use contraception and have regular sexual intercourse.

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4
Q

After how long of trying to get pregnant when should a couple investigate infertility?

A

Investigate at 1 year

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5
Q

Which questions are important in an infertility consultation outside of history?

A

> Are eggs available?
Are sperm available?
Can they meet?
Can embryo implant ?

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6
Q

Within infertility which questions should be asked in a female 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 should be explored within a female examination regarding infertility?

A 
> Weight
> Height
> BMI (kg/m2)
> Fat and hair distribution
> Galactorrhoea
> Abdominal examination
> Pelvic examination
> Hirsutism (Polycystic ovaries, Nonclassic congenital adrenal hyperplasia, androgen-secreting tumours and ovarian hyperthecosis)
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8
Q

How is androgen excess measured?

A

1) Clinical measurement = Ferriman Gallwey score

2) Biochemical measurements:
- Testosterone
- Dehydroepiandrosterone sulphate (DHEAS), if >700 mcg/dl (18.9 mmol/L) adrenal CT is recommended to look for an androgen secreting adrenal tumour
- 17-OH Progesterone

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9
Q

What is the rate of androgen secreting tumours in premenopausal women?

Which percentage of those diagnosed are malignant?

A

0.2% of women with hirsutism have androgen secreting tumours

50% of those diagnosed are malignant at the time of diagnosis

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10
Q

What may be seen in the axilla of a woman with androgen excess?

A

Acanthosis nigricans

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11
Q

How may fibroids present?

A

> Pressure symptoms
Period problems
Infertility

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12
Q

Which baseline investigations would you want to test within infertility - women?

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

> Pelvic Ultrasound

> Physical examination

> Testing for ovulation

> Tubal patency test

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13
Q

Which baseline investigations would you want to test within infertility - men?

A

Male partner’s semen analysis

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14
Q

Investigations at Fertility Clinic?

A

> Pelvic Ultrasound

> Physical examination

> Testing for ovulation

> Tubal patency test

> Male partner’s semen analysis

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15
Q

How is ovulation assessed?

A

1) Concerned about fertility:
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

2) Women with prolonged irregular menstrual cycles should be offered a blood test to measure serum progesterone. 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
3) Women with irregular menstrual cycles should be offered a blood test to measure serum gonadotrophins (FSH and LH )

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16
Q

For women who are not known to have comorbidities (such as pelvic inflammatory disease, previous ectopic pregnancy or endometriosis) which investigations should be performed for suspected tubal and uterine abnormalities?

A

Hysterosalpingography (HSG) 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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17
Q

What should be investigated in a male history in terms of infertility - Developmental?

A

> Testicular descent
Change in shaving
Loss of body hair

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18
Q

What should be investigated in a male history in terms of infertility - Infections?

A

> Mumps

> Sexually transmitted diseases

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19
Q

What should be investigated in a male history in terms of infertility - Surgical?

A

> Varicocele repair

> Vasectomy

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20
Q

What should be investigated in a male history in terms of infertility?

A

1) Developmental
2) Infections
3) Surgical
4) Previous fertility
5) Drugs/environmental
6) Sexual history
7) Chronic medical illness

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21
Q

What should be investigated in a male history in terms of infertility - Drugs/environmental?

A 
> Alcohol
> Smoking
> Anabolic steroids
> Chemotherapy
> Radiation
> Recreational drugs
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22
Q

What should be investigated in a male history in terms of infertility - Sexual history?

A

> Libido- sexual derive
Frequency of intercourse
Previous fertility assessment

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23
Q

What should be investigated in a male history in terms of infertility - Chronic medical illness?

A

Any

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24
Q

Male examination in terms of fertility?

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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25
Q

Increased body fat and decreased muscle mass, loss of pubic, axillary and facial hair may suggest what when there is infertility?

A

Androgen deficiency

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26
Q

What can epididymitis lead to?

A

Causing seminiferous tubular necrosis and disrupts spermatogenesis

27
Q

What examples can lead to epididymitis?

A

1) STD’s:
- Chlamydia trachomatis
- Gonorrhoea
2) Tuberculosis
3) Mumps

28
Q

What is varicocele?

A

Is a dilatation of the pampiniform plexus of the spermatic veins in the scrotum.

29
Q

How can varicocele lead to infertility?

A

Most men with varicocele and presumptive infertility have abnormal semen parameters, including low sperm concentration and abnormal

30
Q

Should men with varicocele be offered surgery for fertility treatment?

A

Men should not be offered surgery or embolisation for varicoceles as a form of fertility treatment because it does not improve pregnancy rates

31
Q

Which side is varicocele more common? Why?

A

Varicoceles are more common on the left side due to the anatomical venous drainage.

There is increased retrograde flow in the left ISV causing dilatation and tortuosity of the pampiniform plexus.

32
Q

How is testicular volume measured?

What is considered small?

A

Orchidometer - below 15 ml is considered small.

33
Q

What is the most common cause of hypogonadism?

A

Klinefelter syndrome—One of the most common causes of primary hypogonadism with impaired spermatogenesis and testosterone deficiency

34
Q

In infertile men with azoospermia, what percentage of men have Klinefelter syndrome?

A

10-15%

35
Q

What it the incidence of Klinefelter syndrome?

A

1 in 500-700 phenotypic males

36
Q

What is Klinefelter syndrome?

A

It is characterized by 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

37
Q

In terms of fertility how can cystic fibrosis effect men?

A

Cystic fibrosis mutations and congenital bilateral absence of the vas deferens
(CBAVD)

38
Q

What is the normal value for semen volume?

A

1.5ml

39
Q

What is the normal value for sperm concentration?

A

15 millions/ml

40
Q

What is the normal value for total sperm number?

A

39 millions

41
Q

What is the normal value for progressive motility?

A

32%

42
Q

What is the normal value for total motility?

A

40%

43
Q

What is the normal value for morphologically normal?

A

4%

44
Q

What are group I ovulatory disorders?

A

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

Examples:

  • Low body weight, stress or exercise-related amenorrhoea
  • Craniopharyngioma or other tumours affecting the hypothalamus
  • Amenorrhoea combined with anosmia - Kallmann’s syndrome
  • Idiopathic
45
Q

What are group II ovulatory disorders?

A

Group II:

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

46
Q

What are group III ovulatory disorders?

A

Group III: ovarian failure (POI).

47
Q

How to aid fertility in group I ovulation disorders?

A

1) Increasing their body weight if they have a BMI of less than19 and/or
2) Moderating their exercise levels if they undertake high levels of exercise.
3) Offer women with WHO GroupI ovulation disorders pulsatile administration of gonadotrophin-releasing hormone or gonadotrophins with luteinising hormone activity to induce ovulation.

48
Q

What are three components of polycystic ovary syndrome?

A

1) Androgen excess:
- Clinical = Hirsutism
- Biochemical (Testosterone)

2) Infrequent periods:
- Anovulation

3) Polycystic ovaries:
- Ultrasound

49
Q

How can ovulation be induced medically?

A

> Clomifene

> Gonadotrophins

50
Q

Why can a BMI <18 lead to infertility in a woman?

A

Functional hypothalamic amernorhea –> Low FSH –> Anovulation

51
Q

How does clomiphene induce ovulation?

A

Clomifene exhibits its OI function by blocking estrogen receptors in the anterior pituitary, leading to increased secretion of FSH.

52
Q

Dose for clomifene?

A

50-150mg Day 2-6

53
Q

What needs to be monitored with clomifene use?

A

1) Follicle scanning in 1st cycle

2) 15% require dose adjustment

54
Q

What are the side effects of clomifene?

A

> Vasomotor

> Visual

55
Q

What is the biggest disadvantage of gonadotrophin therapy?

A

It has multi follicular recruitment and its associated with multiple pregnancy and OHSS

56
Q

If a woman has hydrosalpinges (tubal factor and endometriosis) receives IVF treatment what should occur before?

A

Before vitro fertilisation a woman with hydrosalpinges should be offered laparoscopic salpingectomy surgery

57
Q

How can the “Male factor” increases fertility?

A 
> IVF.ICSI
> Intrauterine insemination 
> Donor insemination
> Surgery:
  - Reversal of vasectomy 
  - Surgical sperm retrieval
58
Q

Investigations for azoospermia?

A

> History
Examination
FSH, LH, Testosterone, Karyotype, PRL
CF screen

59
Q

Types of surgical sperm retrieval?

A

1) Micro-epididymal sperm aspiration

2) Testicular sperm extraction

60
Q

How does IVF treatment work?

A

1) Eggs harvested from ovary
2) Eggs fertilised in the lab with sperm
3) Embryos undergo a number of cell divisions
4) Embryos transferred to the womb

61
Q

What is intracytoplasmic sperm injection (ICSI)?

A

1) Injection of mature eggs with single sperm

2) Incubation overnight

62
Q

How are embryos frozen?

A

Cryopreservation

63
Q

Which changes in society can affect fertility?

A

> Single women
Same sex couple
Older women
Obesity

Year 3 - Reproduction (25 decks)

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