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Reproductive System > Infertility > Flashcards

Infertility Flashcards

1
Q

What is the definition of infertility?

A

An inability for a couple to conceive after 12 months of regular intercourse without use of contraception

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2
Q

What proportion of couples will conceive after a year of effort?

A

80% of couples in the general population will conceive in one year if the woman is under 40 years old, they do not use contraception and they have regular intercourse.
Of those who do not conceive in the first year, about half will conceive in the second year

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3
Q

When should causes of infertility be investigated?

A

At one year of trying with no conception

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4
Q

What should a female history regarding infertility investigate?

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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5
Q

What steps should be taken on a female examination investigating infertility?

A
  • Weight
  • Height
  • BMI (kg/m2)
  • Fat and hair distribution
  • Galactorrhoea
  • Abdominal examination
  • Pelvic examination
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6
Q

What impact can BMI have on fertility?

A

High impact:
BMI too low- body may stop ovulating to prevent pregnancy
BMI too high- can cause a hormonal imbalance, which can cause infertility

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7
Q

What should a pelvic examination on a female patient investigating infertility involve?

A
  • Masses
  • Pelvic distortion
  • Tenderness
  • Vaginal septum
  • Cervical abnormalities
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8
Q

What are the symptoms of fibroids?

A
  • Pressure symptoms
  • Period problems
  • Infertility
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9
Q

What baseline investigations should be offered to the female patient when investigating infertility?

A
  • Rubella immunity
  • Chlamydia testing
  • TSH
  • Mid luteal progesterone (if periods are regular)
  • If periods are irregular- day 1-5 FSH, LH, PRL, TSH and testosterone
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10
Q

What investigation can be done for male-factor infertility?

A

Semen analysis

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11
Q

What investigations can be done at the fertility clinic?

A
  • Pelvic Ultrasound
  • Physical examination
  • Testing for ovulation
  • Semen analysis repeat if required
  • Tubal patency test
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12
Q

What features of a woman’s cycle correspond to ovulation?

A

If a woman has regular, 28 day cycles then she is highly likely to be ovulating
If cycles are less regular or prolonged then she is less likely to be ovulating

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13
Q

What test can be done to confirm ovulation?

A

Blood test to measure serum progesterone at the mid-luteal phase of the cycle (day 21)
Test taken seven days before end of normal cycle and repeated weekly until start of next cycle in women with irregular periods

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14
Q

What blood tests should be offered to women with irregular cycles?

A

Serum progesterone

Serum gonadotrophins, FSH and LH

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15
Q

What should be screened for in infertile women with no known comorbidities and how is it done?

A

Tubal occlusion
Screened for with hysterosalpingography (HSG)
HyCoSy combined ultrasound can also be done

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16
Q

What should be explored in a male history investigating fertility?

A
  • Developmental (testicular descent, change in shaving frequency (loss of androgens), loss of body hair)
  • Infections (mumps, STDs)
  • Surgical (varicocele repair, vasectomy)
  • Previous fertility
  • Drugs/environmental (alcohol, smoking, anabolic steroids, chemotherapy, radiation, recreational drugs)
  • Sexual history (libido, frequency of intercourse)
  • Chronic medical illnesses
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17
Q

What should be involved in a male examination investigating fertility?

A
  • Weight
  • Height
  • BMI (kg/m2)
  • Fat and hair distribution (hypoandrogenism)
  • Abdominal and inguinal examination
  • Genital examination (epididymitis, testes, vas deferens, varicocele)
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18
Q

What are the potential causes of epididymitis?

A

TB
Mumps
Chlamydia
Gonorrhoea

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19
Q

What are the potential complications of epididymitis affecting fertility?

A

Can cause necrosis of the seminiferous tubule and thus disrupt spermatogenesis

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20
Q

What is a varicocoele?

A

Dilatation of the pampiniform plexus of the spermatic veins in the scrotum

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21
Q

How is testicular volume assessed and interpreted?

A

Testicular volume can be assessed using an orchidometer.
Testicular volume <15ml is considered to be small
Any testicle <10ml is very unlikely to be producing sperm

22
Q

What is the lower value for normal for semen volume?

A

1.5ml

23
Q

What is the lower value for normal for sperm concentration?

A

15 million/ml

24
Q

What is the lower value for normal for total sperm number

A

39 million

25
Q

What is the lower value for normal for progressive motility?

A

32%

26
Q

What is the lower value for normal for total motility?

A

40%

27
Q

What is the lower value for normal for morphologically normal sperm?

A

4%

28
Q

In what cases when patients have been trying for a year should they not be referred to the fertility clinic?

A
  • Period irregularity
  • Past medical history
  • Testicular problems
  • Abnormal tests
  • HIV/Hep B
  • Anxiety
  • 35 - 45yrs (after 6 months)
  • > 45 yrs (little can be offered)
29
Q

When is tubal related infertility most common?

A

In multiparous women

30
Q

How are ovulatory disorders classified?

A

Group I: hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism).
Group II: hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome).
Group III: ovarian failure (POI).

31
Q

What are the possible causes of group I ovulatory disorders?

A
  • Low body weight, stress or exercise-related amenorrhoea
  • Craniopharyngioma or other tumours affecting the hypothalamus
  • Amenorrhoea combined with anosmia - Kallmann’s syndrome
  • Idiopathic
32
Q

What can improve the chances of ovulation in group I ovulatory disorders?

A
  • Increasing their body weight if they have a BMI of less than 19 and/or
  • Moderating their exercise levels if they undertake high levels of exercise.
  • Offer women with WHO Group I ovulation disorders pulsatile administration of gonadotrophin-releasing hormone or gonadotrophins with luteinising hormone activity to induce ovulation
33
Q

What is polycystic ovary syndrome associated with?

A
  • Androgen access (hirsutism)
  • Infrequent periods due to anovulation
  • Polycystic ovaries
34
Q

How can polycystic ovaries be diagnosed?

A

With ultrasound, with 20 or more antral follicles of 2 to 9mm per ovary and/or ovarian volume >10cm3 being indicative of a polycystic ovary

35
Q

What are the basics of management of ovulatory disorders?

A
  • Treat underlying cause
  • Weight loss/gain
  • BMI >18 and <35
  • Ovulation Induction (clomifene or gonadotrophins)
36
Q

How does clomifene work?

A

Clomifene works by blocking estrogen receptors in the anterior pituitary to disable the negative feedback system and increase release of FSH

37
Q

What drug class is clomifene?

A

Selective oestrogen receptor moderator

38
Q

What extra step should be taken when clomifene is prescribed?

A

Follicle scanning should be done to monitor the effects, with 15% requiring a dosage adjustment

39
Q

What risk is associated with gonadotrophin therapy and how is this managed?

A

Gonadotrophin therapy can cause multiple follicles to maturate so there is a risk of multiple pregnancy and ovarian hyperstimulation syndrome (OHSS)
Every ovulation induction cycle using gonadotrophin therapy should be monitored with scans

40
Q

How is clomifened administered?

A

50-150mg in days 2-6 of the cycle

41
Q

How is gonadotrophin therapy administered?

A

Injections of FSH and can be given for 3-6 cycles

42
Q

How are hydrosalpinges managed?

A

Salpingectomy (preferably by laparoscopy) before IVF treatment to increase chance of a live birth

43
Q

What measures can be helpful in male factor infertility?

A
  • Urologist appointment
  • IVF/ICSI
  • Intra-uterine insemination
  • Surgery (removal of vasectomy (not available on NHS) or surgical sperm retrieval)
  • Donor insemination
44
Q

What is azoospermia?

A

When the semen that is produced contains no sperm

45
Q

What are the potential causes of azoospermia?

A

Testicular- normo/hyper/hypo gonadotrophic

Post-testicular- iatrogenic, congenital, infective

46
Q

What investigations can be done for azoospermia?

A
  • History
  • Examination
  • FSH, LH, Testosterone, Karyotype, PRL
  • CF screen
47
Q

How can surgical sperm retrieval be done?

A

Micro-epididymal sperm aspiration

Testicular sperm extraction

48
Q

When should IVF be offered?

A

Women with unexplained infertility should be advised to try regular intercourse for two years before being offered IVF

49
Q

How is IVF done?

A

Gonadotrophins used to overstimulate egg production

Eggs harvested and mixed with sperm

50
Q

What causes of infertility can be assisted with IVF?

A

Tubal
Male factor
Ovulatory
Unexplained infertility

Reproductive System (30 decks)

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