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Reproduction > Infertility > Flashcards

Infertility Flashcards

1
Q

How many couples will experience infertility

A

1 in 6

Around half will go onto conceive spontaneously whilst the other half will need assisted conception

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2
Q

Why might the incidence of assisted conception be on the rise

A 
Increasing parental age
Increasing chlamydia
Increasing obesity 
Male factor infertility rising
Increasing range of ACT and awareness of it  
Improved success rates
Same sex couples and surrogacy
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3
Q

What are some of the indications for assisted conception treatment

A

When at least one partner has no biological children Male factor infertility
Tubal diseases
Endometriosis
Ovulation disorders
PIGD for inherited disorders is needed
Fertility preservation in cancer patients
Single, same-sex or transgender parents

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4
Q

What must the patient do before they start IVF

A

Limit alcohol intake to 4 units per week - F
Stop smoking - must have not smoked for at least 3 months
Optimal weight in both M and F - BMI between 19 and 29 is optimal
Start taking folic acid - 0.4mg/day prior to conception then up to 12 weeks
Get rubella vaccine if not already had it
Reduce occupational hazards if possible
Check smears are up to date
Screen for BBV

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5
Q

How much folic acid should you take if wanting to get pregnant

A

0.4mg per day from before conception up until 12 weeks of pregnancy
5mg if you are a high risk mum - obese or diabetic

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6
Q

What checks should the doctor do before referring someone for IVF

A 
Take a full history 
Check female rubella status and immunize if not already 
Check cervical smears are up to date 
Swab for chlamydia and gonorrhea 
Screen for blood borne viruses
Check occupation and advise if there are any hazards 
Check the drugs they are on are safe 
Assess ovarian reserve
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7
Q

What are the indications for intra-uterine insemination

A 
Sexual problems 
Same sex relationship
Discordant BBV 
Abandoned IVF
Mild male factor infertility
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8
Q

What is intrauterine uterine insemination

A

Prepared semen inserted into uterine cavity around time of ovulation

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9
Q

What are the indications for IVF

A

Unexplained infertility for over 2 years
Pelvic disease - fibroids, endometriosis
Anovulatory infertility - after failed induction
Failed insemination (6 cycles)

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10
Q

How are oocytes grown and collected for IVF treatment

A

Down regulation of natural cycle with GnRH analogues - takes a few weeks
Then ovarian stimulation with FSH/LH to cause follicular development - can be self-admin
Monitor ovary response to drugs via US - see follicles developing
HCG injection to cause ovulation - done at final stage of oocyte maturation
Collection of oocytes in theatre under US guidance

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11
Q

What are the side effects of GnRH analogues

A 
Hot flushes 
Mood swings 
Nasal irritation 
Headaches
Basically an artificial menopause
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12
Q

How is a semen sample collected

A

Need to be abstinent for 72 hours before
Produce sample in ward or at home (need to get it to hospital within 1 hr)
Advised to keep it close to body to maintain temperature
Ideally caffeine and alcohol should be avoided in the days
leading up to the test.

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13
Q

How do you assess semen

A

Volume in ml
Density - concentration of sperm (should be over 15 million)
Total sperm number
Motility - what proportion are moving (should be at least 32%)
Progression - how well they move
Sperm morphology
pH

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14
Q

What are the risks of oocyte collection

A

Bleeding
Pelvic infection
Failure to obtain oocytes
Damage to the viscera

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15
Q

At what day are the embryos transferred or preserved

A

Day 5 - blastocyst stage

Usually only transfer 1 embryo

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16
Q

What are the indications for ICSI

A

Severe male factor infertility
Previous failed fertilisation with IVF
Preimplantation genetic diagnosis

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17
Q

If the father has azoospermia how do you get sperm

A

Surgical Sperm Aspiration
Taken from epididymis if obstructive
Taken directly from testicular tissue if not

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18
Q

What are some of the complication of assisted conception

A 
Ovarian hyper-stimulation syndrome 
Multiple pregnancy 
Ectopic pregnancy
Increased miscarriage risk 
Surgical risk of oocyte collection
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19
Q

How does Ovarian hyper-stimulation syndrome present

A

Deranged bloods - release of inflammatory markers and vasoactive substances
Hyponatremia and hyperkalaemia

This leads to fluid shift causing: 
Abdominal pain and bloating 
N and V 
Ascites - clinical or on US
Large ovaries

Severe cases can cause VTE and ARDS

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20
Q

How do reduce risk of ovarian hyper-stimulation syndrome after embryo transfer

A

Monitor with scans and bloods
Reduce thrombosis risk - stockings, fluids etc
Analgesia

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21
Q

How can you reduce the risk of ovarian hyper-stimulation syndrome

A

Low dose protocols

Use an antagonist for suppression

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22
Q

How can you manage ovarian hyperstimulation syndrome

A

Analgesia

Hospital admission if required IV fluids/more intensive monitoring/paracentesis

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23
Q

How can we reduce the incidence of multiple pregnancy from IVF

A

Move to blastocyst transfer
Improved cryopreservation
Only do single embryo transfer

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24
Q

What is the success rate of IVF

A

around 35%

Success is age dependant as well

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25
Q

What is the key to sexual differentiation

A

The SRY region of the Y chromosome

If present it triggers male development

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26
Q

Describe what happens to the Wolffian and Mullerian ducts in males

A

W = forms the reproductive tract (epididymis, vas deferens etc)

M - degenerates

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27
Q

Describe what happens to the Wolffian and Mullerian ducts in women

A

W = degenerate

M = forms the reproductive tract - uterus, fallopian tubes etc

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28
Q

What is responsible for the formation of the external genitalia

A

DHT - form of testosterone
Its presence causes male genitals to form
It’s absence leads to female genitals

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29
Q

At what point can you determine sex on an US

A

From 16 weeks

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30
Q

Describe androgen insensitivity syndrome

A

It’s a congenital insensitivity to androgens - X-linked
Will have male karyotype and testis but female external genitalia
Often thought to be girls and present with primary amenorrhea or lack of pubic hair

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31
Q

What is the blood supply to the testes

A

Testicular artery - branch of aorta

Testicular veins - drain into left renal vein, right drains straight into the IVC

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32
Q

Why do the testes need to descend

A

Need to be kept at a lower temperature, outside of the body

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33
Q

Which muscles are responsible for thermal regulation of the testes

A

Dartos and cremaster muscle

Cause contraction of scrotum to lower/raise the testes

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34
Q

What connects the testes to the body

A

Spermatic cord - contains arteries, veins, lymphatics and the vas deferens

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35
Q

What covers the testes

A

A double layer of the tunica vaginalis (peritoneal remnant)

Then the tunica albuingea – firm fibrous covering

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36
Q

What is cryptorchidism

A

Undescended testes in adolescence/adult

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37
Q

When should the testes have descended

A

By 6-9 months of age

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38
Q

What is the treatment for crytochidism

A

Orchidopexy - surgery to move teste into scrotum
Needs to be done by 12 months to prevent infertility and by 12 years to reduce cancer risk

If undescended in an adult consider removing the teste (orchiectomy ) due to high cancer risk

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39
Q

What is the corpus cavernosum

A

Two columns of tissue running along the sides of the penis.

Blood fills this tissue to cause an erection

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40
Q

What is the corpus spongiosum

A

A column of sponge-like tissue running along the front of the penis and ending at the glans penis
It fills with blood during an erection, keeping the urethra, which runs through it, open

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41
Q

What are the functions of the Sertoli cells

A

Forms the blood-testes barrier - protects the spermatozoa from antibodies
Provides nutrients
Phagocytosis of defective sperm
Secretes the seminiferous tubule fluid - needed to carry sperm to epididymus
Secretes androgen binging globulin
Secretes inhibin and activin hormones - regulates sperm production

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42
Q

What is the function of androgen binging globulin

A

Binds testosterone so concentration remains high in lumen

Essential for sperm production

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43
Q

How is GnRH released

A

Released from hypothalamus in bursts every 2-3 hours
This starts at age 8-12
Under negative feedback control from testosterone

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44
Q

What is the function of GnRH

A

Stimulates anterior pituitary to produce LH and FSH

In females this is cyclical but in men it is not

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45
Q

What is the function of LH in men

A

Acts on the Leydig cells to regulate testosterone secretion

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46
Q

What is the function of FSH in men

A

Acts on Sertoli cells to enhance spermatogenesis

Regulates by negative feedback from inhibin released from the sertoli cells

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47
Q

How is testosterone produced

A

Its a steroid hormone derived from cholesterol
Produced in the Leydig cells
Secreted into blood and seminiferous tubules for sperm production
Negative feedback on hypothalamus and pituitary gland

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48
Q

What is the function of testosterone before birth

A

It masculinises reproductive tract and promotes descent of testes

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49
Q

What is the function of testosterone during puberty

A

Promotes puberty and male characteristics

Growth and maturation male reproductive system

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50
Q

What is the function of testosterone in adulthood

A

Controls spermatogenesis - stimulates it
Secondary sexual characteristics - male body shape, deep voice
Libido and erections
Aggressive behaviour

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51
Q

Where are inhibin and activin produced

A

Secreted by the Sertoli cells

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52
Q

What are the functions of inhibin and activin

A

Inhibin inhibits FSH release

Activin stimulates it

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53
Q

Where does fertilisation take place

A

The ampullary region of the fallopian tube

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54
Q

What are the functions of the epididymis and vas deferens

A

Exit route from testes to urethra - sperm pass into epididymis then into vas deferens

Epididymus also concentrates and store sperm
Site for sperm maturation

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55
Q

What are the functions of the seminal vesicles

A 
Produce seminal fluid and releases into ejaculatory duct
Supply fructose - nourish sperm
Secrete prostaglandins (stimulates motility)
Secrete fibrinogen (clot precursor)
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56
Q

What are the functions of the prostate gland

A

Produces alkaline fluid (neutralizes vaginal acidity)

Produces clotting enzymes to clot semen within female

57
Q

What are the functions of the bulbourethral glands

A

Secrete mucus to act as lubricant and neutralises any acidity, prior to
ejaculation

58
Q

Describe the path of sperm from the testes to the female

A

Testes → epididymis → vas deferens → ejaculatory duct → urethra
Contraction of the sex glands and vas deferens expels semen into the urethra
The smooth muscles of the urethra and erectile muscles contract lead to ejaculation

59
Q

What is the definition of male infertility

A

Infertility resulting from failure of the sperm to normally fertilise the egg
The presence of one or more abnormalities in the
semen analysis or the presence of inadequate sexual or ejaculatory function

60
Q

What fraction of infertility cases are due to male factor

A

Approximately 1/3

61
Q

What is the trend in male infertility

A

It is on the rise

62
Q

What causes male infertility

A

Most commonly idiopathic

Obstructive or non obstructive defects

63
Q

Give examples of obstructive causes of male infertility

A

Vasectomy
Cystic fibrosis - lack of vas deferens
Infections - can lead to fibrosis and block pathway

64
Q

Give examples of non-obstructive causes of male infertility

A

Cryptorchidism - undescended testes
Mumps orchitis - reduced spermatogenesis
STIs - can cause epididymitis and orchitis
Chemo/radiotherapy
Testicular tumour
Genetic disorders - Klinefelter’s or Y microdeletions
Semen abnormality - e.g. low count/motility or absent sperm
Robertsonian Translocation - any type increases infertility risk

65
Q

List some endocrine causes of male infertility

A

Hypothalamic causes: idiopathic, tumours, Kalman’s syndrome, anorexia
Pituitary tumours: acromegaly, Cushing’s disease, hyperprolactinaemia
Thyroid Disorders: hyper or hypo
Diabetes - decreases testosterone and sexual function
CAH - increases testosterone
Androgen insensitivity
Steroid abuse

66
Q

How would you examine an infertile male

A

General - look for secondary sexual characteristic, gynaecomastia
Genital exam - Testicular volume, presence of vas and epi, scrotal swelling, evidence of surgery
Take bloods for hormone levels
Take a semen sample

67
Q

What is considered normal testicular volume

A 
Pre-puberty = 1-3mls
Adults = 12-25mls

Measured with an orchidometer

68
Q

A low testicular volume makes infertility likely - true or false

A

TRUE

If below 5ml unlikely to be fertile

69
Q

What are the clinical features of obstructive azoospermia

A

Normal testicular volume
Normal secondary sexual characteristics
Vas deferens may be absent

70
Q

What are the endocrine features of obstructive azoospermia

A

Normal LH, FSH and testosterone levels

71
Q

What are the features of non-obstructive azoospermia

A

Low testicular volume
Reduced secondary sexual characteristics
Vas deferens present
High LH, FSH and low/normal testosterone

72
Q

How can you treat male infertility

A

Treat any specific cause e.g. reversal of vasectomy if vasectomy
May need intrauterine insemination (mild cases) or ICSI (more severe) to conceive
Donor insemination if sperm are non viable or no sperm

73
Q

What lifestyle changes can improve male fertility

A 
Frequency sexual intercourse: 2-3 X per week 
Avoid lubricants that are toxic to sperm
Alcohol: < 5 units per week
Stop smoking
Get BMI below 30
74
Q

Are vasectomies reversible

A

Yes

Success rate decreases the longer you leave it though

75
Q

Fibroids in which location are the most likely to cause difficulty conceiving

A

Submucosal

They lie in the uterine cavity and disrupt the process of embryo implantation

76
Q

Which questions should be asked of both partners in an infertility history

A 
BMI
Smoking and alcohol
PMHx = particularly previous pelvic infections/STI
Drug history
Intercourse regularity 
Sexual function 
Family history
Environmental risks - exposure to pesticides
or excessive heat on the testes
77
Q

Which female specific questions should be asked in an infertility history

A

Obstetric history
Gynae history including menstrual cycle
Previous contraception

78
Q

Which male specific questions should be asked in an infertility history

A

Previously fathered any children/ caused a pregnancy
Previous testicular trauma
Are they able to get and maintain an erection and ejaculate

79
Q

What examination would you perform on the female partner in an infertility history

A

BMI
Check for secondary sexual characteristics
Bimanual and speculum pelvic exam
Check they are up to date with smears - offer if due
Swab for STIs

80
Q

What examination would you perform on the male partner in an infertility history

A

BMI
Check for secondary sexual characteristics
Testicular volume
Genital examination

81
Q

What is oligospermia

A

A low sperm count

Your sperm count is considered lower than normal if you have fewer than 15 million sperm per milliliter of semen

82
Q

Which investigations should be performed on an infertile male to establish cause

A

Hormone profile - LH,FSH and testosterone
High FSH signifies spermatogenesis
failure

Genetic testing- cystic fibrosis screening and y
chromosome deletion

83
Q

How do you induce ovulation in a patient with PCOS

A

Clomiphene induction
Will need hystersalpingogram prior to clomiphene
induction to ensure tubal patency.
Also need to ensure BMI is within range to be eligible

84
Q

What is the definition of subfertility

A

Failure to conceive despite regular sex over 12 months in the absence of known reproductive pathology

85
Q

What is primary subfertility

A

The couple have never been able to conceive

86
Q

What is secondary subfertility

A

Couple has previously conceived but is no longer able to

Includes miscarriages, ectopics and stillbirths

87
Q

Which factors increase the risk of infertility

A

Increased female age (>35)
Longer duration of infertility, Lack of previous pregnancy
The cause of the subfertility

88
Q

What is the risk of rubella infection in the 1st trimester

A

50% of babies will develop congenital rubella syndrome

Presents with microcephaly, PDA, cataracts and rashes

89
Q

How can you prevent congenital rubella syndrome

A

Give a booster MMR to unvaccinated mums during pregancy

90
Q

List some of the short term consequences of PID

A

Tubo-ovarian abscess
Salphigitis, endometritis, oophoritis etc.
Peritonitis
Fitz-Hugh-Curtis syndrome - inflammation of peritoneum, liver capsule and diaphragm

91
Q

List some of the long term consequences of PID

A

Chronic pelvic pain
Infertility - scarring and narrowing of tubes
Ectopic - increased risk due to scarring

Caused by blockage/damage to the tube

92
Q

How are progesterone levels used in fertility assessment

A

Corpus luteum produces progesterone - rises in second half of cycle
Progesterone level is used as evidence of egg release

You test the midluteal progesterone level (day 21 if 28 day cycle or 7 days prior to expected period)

93
Q

What is the purpose of ovarian drilling in the treatment of infertility

A

Ovarian drilling aims to allow release of the egg
Destroys stroma which reduces androgen-secreting tissue leading a restoration of the normal LH:FSH ratio and a fall in androgens.
Effective for 8-10 months following treatment

94
Q

Which drugs are used for ovulation induction in PCOS

A

Anti-oestrogens - clomiphene citrate or tamoxifen
Taken daily from day 2 of cycle for 5 days

Other option is aromatase inhibitors - letrozole/anastrozole

95
Q

What is the 1st line fertility treatment in PCOS

A

Ovulation induction - usually with clomifene citrate

Ovulation occurs in 70-80% but 40-50% conceive

96
Q

How does the obesity seen in PCOS contribute to infertility

A

PCOS causes central obesity which leads to insulin insensitivity which in turn contributes to anovulation
Weight loss can improve fertility
Metformin can also be added to treatment to help

97
Q

Regular cycles are suggestive of ovulation - true or false

A

True

Irregular is more suggestive of anovulation

98
Q

Ovulation kits are not recommended by the fertility specialists - true or false

A

True

Neither is temperature monitoring or mucus consistency

99
Q

The WHO splits ovulatory disorders into how many groups

A

3 main groups
Group 1 = hypothalamic causes
Group 2 - hypothalamic pituitary dysfunction
Group 3 - ovarian failure

100
Q

List causes of infertility in the Group 1 = hypothalamic causes

A

Stress, excessive exercise
Anorexia/bulimia
Kalman’s syndrome - GnRH deficiency (genetic)
Isolated gonadotrophin deficiency

101
Q

If infertility is caused by a hypothalamic disorder (group 1) what will the hormone levels be

A

Low FSH and oestrogen levels
Normal prolactin
Negative progesterone challenge

102
Q

List causes of infertility in Group 2 = hypothalamic pituitary dysfunction

A

PCOS - normogonadotrophic normo-oestrogenic anovulation
Hyperprolactinaemia
Sheehan’s Syndrome (post-partum hypopituitarism)
Pituitary adenomas

103
Q

List causes of infertility in Group 3 = ovarian failure

A

Any form of ovarian failure or resistant ovary

104
Q

If infertility is caused by ovarian failure (group 3 ) what will the hormone levels be

A

High gonadotrophins - LH/FSH

Low oestrogen

105
Q

How does a polycystic ovary present on US

A

Increased ovarian volume (>10mls)
More than 12 follicles between 2-8mm
Can be unilateral or bilateral

106
Q

If infertility is caused by PCOS (group 2 ) what will the hormone levels be

A 
Elevated serum LH 
LH/FSH ratio >2 
Normal estradiol 
Low progesterone 
Normal or slightly high prolactin 
Raised testosterone - main clue
Impaired glucose tolerance.
107
Q

Which lifestyle changes can help treat the infertility seen in PCOS

A

Weight loss and exercise to decrease BMI

Must get BMI under 30 before ovulation treatment can be started

108
Q

How does clomifene citrate work to increase fertility

A

It is a selective oestrogen receptor modulator which blocks oestrogen negative feedback effect on hypothalamus resulting in more pulsatile GnRH secretion and therefore FSH and LH

109
Q

How can metformin aid fertility in PCOS patients

A

It is an nsulin-sensitiser so improves glucose tolerance, decreases androgen levels and improves ovulation rate.

110
Q

When is IVF used to treat infertility in PCOS

A

When 1st or 2nd line treatment have not worked

111
Q

What are some of the side effects of clomifene citrate

A

hot flushes and sweating
Increased risk of multiple pregnancy
Risk of ovarian cancer (with long term use)

112
Q

List factors which increase your chance of conceiving

A

Young maternal age
Healthy BMI
Being a non-smoker
Timing intercourse with ovulation

113
Q

Why are men with CF often infertile

A

In the majority there is an obstruction or absence of the vas deferens bilaterally - Congenital Bilateral Absence of Vas Deferens (CABVD)
No way for sperm to be transported an meet semen
Sperm still produced normally though

114
Q

Why does cryptorchidism lead to infertility

A

The testes are not in the ideal environment for the development of the testes and the production of spermatozoa - e.g. increased temperature inside the body

115
Q

How can infections lead to male factor infertility

A

If severe can cause fibrosis and blockages
Mumps and STIs can cause orchitis/epididymitis which can damage the
seminiferous tubules and affect the process of sperm cell production
STIs can also affect the motility, morphology and quantity of the sperm

116
Q

What is globozoospermia

A

Specific sperm abnormality
where the spermatozoa have rounded heads, instead of the usual
oval shape, and no acrosome
Without the acrosome they are unable to fuse with the ovum

117
Q

What are the endocrine features of non-obstructive male factor infertility

A

High LH and FSH and low testosterone.

118
Q

How does hyperprolactinaemia cause infertility

A

High levels of prolactin can prevent ovulation from occurring
Similar to it’s role in pregnancy and breastfeeding

119
Q

How does hyperprolactinaemia cause infertility

A

High levels of prolactin can prevent ovulation from occurring
Similar to it’s role in pregnancy and breastfeeding

120
Q

How does PCOS present

A

Anovulation - oligomenorrhea or amenorrhea
Polycystic Ovaries - seen on US
Hyperandrogenism (clinical or biochemical) - hirsutism, weight gain, acne etc .

121
Q

Why does PCOS cause infertility

A

The overproduction of oestrogen by ovaries cause them not to release an ovum
In the long term, increased levels of testosterone can also impair ovum quality and mean that any ovum that are released are of poorer quality

122
Q

Women with PCOS also have an increased

risk of ovarian torsion - true or false

A

True

123
Q

How does premature ovarian failure present

A

Hot flushes and night sweats
Atrophic vaginitis Oligomenorrhea, or amenorrhea

Basically menopause

124
Q

What can cause premature ovarian failure

A

Often cause is unknown
Can be caused by genetic
disorders - Turner’s syndrome and fragile X syndrome
Exposure to chemotherapy or radiotherapy - toxin-induced ovarian failure
Autoimmune response to ovarian tissue.

125
Q

Where in the body does spermatogenesis take place

A

In the seminiferous tubules, located

inside the testes

126
Q

What is the purpose of the acrosome in sperm cells

A

Found around the sperm head

Contains enzymes for penetrating the ovum - allows it to bind to the zona pellucida

127
Q

What is tubal factor infertility

A

Where disease of the fallopian tubes is the underlying cause
There is a blockage (complete or partial) of the tube/tubes preventing sperm from meeting the ovum
Can be infective or non-infective

128
Q

List infective causes of tubal factor infertility

A

PID
Trans-peritoneal spread
of infection, such as appendicitis or intra-abdominal abscess,
Iatrogenic source of
infection, such as following IUD insertion or hysteroscopy

129
Q

What causes PID

A

Usually a bacterial infection that spreads from the vagina or cervix into the uterus and fallopian tubes
Commonly STI like chlamydia or gonorrhea

130
Q

How does PID present

A 
Abdominal and/or pelvic pain
Dyspareunia
Dysmenorrhea
Intermenstrual bleeding
Unusual vaginal discharge

If severe it can present with severe abdominal pain, fever and
nausea and vomiting.

131
Q

How can you treat PID

A

Course of Metronidazole and Ofloxacin
If tubes get blocked - laparoscopic removal of scarring and adhesions after the acute inflammation
has been resolved

132
Q

List non-infective causes of tubal factor infertility

A

Endometriosis - can block/scar the tubes
Salpingitis Isthmica Nodosa - nodular scarring of the fallopian tube due to infalmmation
Uterine polyps
Uterine fibroids

133
Q

Why do polyps/fibroids cause infertility

A

Can develop at the opening of the fallopian tubes and ca n block these tubes
If in the endometrium they can interfere with the process of implantation

134
Q

How do you investigate tubal patency

A

Laparoscopy - preferred where there is possible tubal disease or pelvic
inflammation

If there are no known risk factors for tubal or pelvic disease and laparoscopy is
contraindicated then a hysterosalpingogram can be
performed.

135
Q

What is the indication for hysteroscopy in infertility

A

Indicated if known or suspected endometrial pathology

136
Q

What is the indication for scrotal US in infertility

A

Indicated if abnormality on male genital examination

137
Q

How many cycles of IVF are offered in the NHS

A

Up to 3 cycles

138
Q

How long after IVF do you take a pregnancy test

A

16 days after oocyte recovery.

Reproduction (16 decks)

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