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Obstetrics + Gynaecology > Infertility > Flashcards

Infertility Flashcards

1
Q

What is the definition of infertility?

A

Failure to achieve clinical pregnancy after 12 months or more of regular unprotected sex, in a couple who have never conceived a child

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2
Q

How are primary and secondary infertility defined?

A 
Primary
- couple have never conceived
Secondary
- couple have previous pregnancy
- includes stillbirth, miscarriage and ectopic
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3
Q

What are the three categories of male infertility?

A

Idiopathic (most common)
Obstructive
Non-obstructive

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4
Q

What are the main causes of obstructive male infertility?

A

Cystic fibrosis - congenital bilateral absence of the vas deferens
Vasectomy

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5
Q

What are the endocrine features of obstructive male factor infertility?

A

Normal LH, FSH and testosterone

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6
Q

How can non-obstructive causes of male infertility be classified?

A 
Congenital - cryptorchidism (undescended testes)
Chromosome abnormality
Infection
Endocrine
Testicular tumours
Sperm abnormalities
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7
Q

Which chromosome abnormalities cause male infertility?

A

Klienfelter’s syndrome - 47 XXY
Microdelections of the Y chromosome
Robertsonian translocation

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8
Q

Which infections can cause male infertility?

A 
Mumps orchitis (usually temporary)
STIs
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9
Q

What are the endocrine causes of male infertility?

A 
Pituitary tumours
Hypothalamus disorders
Thyroid disorders
Diabetes
Congenital adrenal hyperplasia
Steroid abuse
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10
Q

How can female factor infertility be classified?

A

Anovulatory

Tubal factor

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11
Q

What are the causes of anovulatory infertility?

A 
Hypothalamic:
- anorexia
- bulimia
- excessive exercise
Pituitary:
- hyperprolactinaemia 
- pituitary adenoma
- Sheehan's syndrome
Ovarian:
- PCOS
- premature ovarian failure

Others:

  • CKD
  • hormonal medications
  • congenital adrenal hyperplasia
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12
Q

What are some of the causes of premature ovarian syndrome?

A 
Turner's syndrome
Fragile X syndrome
Chemo or RT
Autoimmune
Often unknown
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13
Q

What are the causes of tubal factor infertility?

A

Infective:
- PID
- appendicitis or intra-abdominal abscess
- iatrogenic e.g. IUD insertion, hysteroscopy, HSG
Non-infective:
- endometriosis
- salpingitis isthmica nodosa (SIN) - scarring following inflammation
- uterine polyps or fibroids blocking tube

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14
Q

How is PID treated if diagnosed at the time of infection?

A

Metronidazole + Ofloxacin

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15
Q

Which tests are done initially for infertility?

A 
History + examination
Pelvic exam of female
Endocervical swab for chlamydia + smear if due
TV USS 
Semen analysis
- if abnormal, male genital exam
Investigate tubal patency
- laparoscopy
- HSP
Test for ovulation:
- mid-luteal progesterone
Chromosome analysis
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16
Q

What are you looking for on examination of male genitals?

A 
Descended testes
Bilateral vas deferens
Bilateral epididymus
Varicocele or other scrotal swelling
Testicular volume within normal range (12-25 ml)
Signs of gynaecomastia
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17
Q

Which parameters are measured on semen analysis?

A 
Volume of semen
pH
Concentration
Total sperm number
Total motility
Progressive motility
Morphology
18
Q

Which factors need to be adhered to in order to keep semen analysis accurate?

A 
Complete sample obtained
Analysed within 1 hour of production
Kept at body temperature
Man in good health
Abstain from ejaculation for 72 hours
Avoid caffeine and alcohol in days leading up to test
19
Q

What are the guideline for testing tube patency?

A

Laparoscopy if there is possible tubal disease or pelvic inflammation
- e.g. PID or known previous pelvic pathology such as ectopic
Hysterosalpingogram if:
- no known risk factors for tubal/pelvic disease
- laparoscopy contraindicated e.g. obesity, Crohns

20
Q

What is the definition of assisted conception treatment (ACT) and what are the different types?

A

Treatment for infertility which involves gametes outside the body

  • donor insemination
  • intra-uterine insemination (IUI)
  • in vitro fertilisation (IVF)
  • intra-cytoplasmic sperm injection (ICSI)
21
Q

What are the indications for ACT?

A

Couples with fertility issues where at least one partner doesn’t have any biological children
Same sex couples
Fertility preservation
- cancer treatment
- gender reassignment surgery
To avoid transmission of BBVs e.g. HIV
Preimplantation diagnosis of certain inherited disorders

22
Q

How many cycles of IVF/ICSI can couples receive on the NHS?

A

3

23
Q

What are the criteria for IVF on the NHS?

A

In relationship for > 2 years
Non smoking for 3 months before treatment + during treatment
No alcohol
Female BMI between 18.5 to 30
Neither undergone voluntary sterilisation
Female up to date smears, screened for BBV and rubella immunised

24
Q

How does IVF on NHS differ for women age 40-42?

A

Only 1 full cycle offered

25
Q

What are the indications for intra-uterine insemination?

A

Sexual dysfunction
Female same sex (donor sperm)
Male same sex (surrogacy)

26
Q

What are the 5 steps of IVF/ICSI?

A
  1. Down regulation
  2. Ovarian stimulation
  3. Oocyte collection
  4. Fertilisation
  5. Embryo transfer
27
Q

What happens in down regulation?

A

GnRH analogues/agonists used to induce temporary menopause

28
Q

What happens during ovarian stimulation?

A

Gonadotropin hormone injections given for 10-14 days to induce follicular development + oocyte maturation
GnRH agonist used to prevent LH surges

HCG injection administered to stimulate final maturation of oocytes

29
Q

What happens during oocyte collection?

A

US guided needle aspiration of oocytes –> embryology lab

30
Q

What happens during fertilisation?

A

IVF:
- sperm + oocyte placed in petri dish

ICSI:
- one sperm immobilised and injected into oocyte

31
Q

What happens during embryo transfer?

A

Normally one (maximum two) inserted into uterus

Progesterone suppositories used for 2 weeks

32
Q

When does embryo transfer take place?

A

Day 5 usually (blastocyst stage)

33
Q

What are the indications for IVF?

A 
Unexplained infertility > 2 years
Pelvic disease (tubal, endometriosis, fibroids)
Anovulatory infertility (after failed ovulation induction)
34
Q

What are the indications for ICSI over IVF?

A

Severe male factor infertility
Previous failed fertilisation with IVF
Pre-implantation genetic diagnosis

35
Q

When is surgical sperm aspiration indicated and where is it aspirated from?

A

Azoospermia (little or no sperm)

  • if obstruction –> taken from epididymus
  • if non-obstructive –> taken from testicular tissue
36
Q

What are the complications of ACT?

A 
Ovarian hyperstimulation syndrome (OHSS)
Multiple pregnancy 
Ectopic pregnancy
Increased risk of miscarriage
Surgical risk from oocyte collection - infection, bleeding, damage to viscera
37
Q

What causes OHSS?

A

Large number of follicles + high estradiol levels –> release of inflammatory markers and vasoactive substances
–> fluid shift in abdomen

38
Q

What are the symptoms of OHSS?

A

Bloating
Abdominal distension
Nausea and vomiting

39
Q

What are the complications of severe OHSS?

A

VTE

ARDS

40
Q

How is OHSS managed?

A 
Before embryo transfer:
- elective freeze
- single embryo transfer
After embryo transfer:
- monitor with USS and blood tests
- reduce VTE risk (fluids, stockings, fragmin) 
- analgesia
Admit if requiring IV fluids, intensive monitoring or paracentesis
41
Q

When is the blood test for ovulation done?

A

Mid luteal progesterone
–> 7 days before end of cycle
e.g. day 21 of 28 day cycle
day 28 of 35 day cycle

Obstetrics + Gynaecology (22 decks)

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