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Obs & Gynae > Infertility > Flashcards

Infertility Flashcards

1
Q

Investigation and infertility should be started when couple have been trying to conceive without success for __ months

A

12+ months

*reduces to 6 months if woman >35 yo as ovarian stores reduced and time more precious!

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2
Q

What are causes of infertility?

List the 5 broad options.

A 
Sperm problems
Ovulation problems
Tubal problems
Uterine problems
Unexplained problems

*40% of infertile couples have a mix of male and female causes

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3
Q

What are conservative management (advice) for couples trying to get pregnant?

A
  • Woman should take 400mcg folic acid daily
  • Aim for healthy BMI
  • Avoid smoking + alcohol
  • Reduce stress as can affect libido
  • Aim for sex every 2-3 days
  • Avoid timing intercourse

*timed intercourse to coincide with ovulation is not necessary or recommended as can lead to increased stress and pressure in the relationship!

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4
Q

What are initial investigations for fertility that are performed in primary care?

A 
BMI (low = anovulation, high = PCOS)
Chamydia screening
Semen analysis
Female hormonal testing
Rubella immunity in mother
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5
Q

What hormones are tested for in the female during initial investigations for fertility in primary care?

A 
Serum LH/FSH
Serum progesterone
Anti-Mullerian hormone
TFT (when symptoms are suggestive)
Prolactin (when galactorrhoea or amenorrhoea exists) - hyperprolactinaemia is cause of anovulation!
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6
Q

High FSH can suggest infertility. Why?

A

Poor ovarian reserve - pitutary gland produces extra FSH to try and stimulate follicular development

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7
Q

High LH can suggest infertility. Why?

A

PCOS

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8
Q

High progesterone on day 21 indicates what?

A

Ovulation has occured, corpus luteum has formed and has started secreting progesterone.

*Not present if no ovulation!

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9
Q

What does anti-Mullerian hormone reveal in regards to female fertility?

A

Ovarian reserve

released by granulosa cells in follicules and falls as eggs are depleted. High level = good ovarian reserve

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10
Q

What are further investigations for infertility performed in secondary care?

A

USS Pelvis - polycystic ovaries, structural abnormalities in uterus

Hysterosalpingogram - patency of fallopian tubes

Laparoscopy and dye test - patency of fallopian tubes, adhesions and endometriosis

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11
Q

How is anovulation managed in infertility?

A

Weight loss (overweight pateints with PCOS)

Clomifene (SERM - stimulate ovulation) or Letrozole - aromatase inhibitor with anti-oestrogen effects

Gonadotrophics (stimulate ovulation in women resistant to clomifene)

Ovarian drilling with laparoscopic surgery. - Improves hormonal profile and results in regular ovulation and fertility (use if PCOS)

Metformin (if insulin insensitivity and obesity - usually with PCOS)

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12
Q

How are tubal factors managed in infertility?

A

Tubal cannulation during hysterosalpingogram

Laparscopy to remove adhesions or endometriosis

IVF

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13
Q

How are uterine factors managed in infertility?

A

Surgery - correct polyps, adhesions or structural abnormalities affecting fertility

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14
Q

How are sperm problems managed in infertility?

A

Surgical sperm retrieval (if blockage)

Surgical correction of obstruction in vas deferens

Intra-uterine insemination - collect and separate out high-quality sperm, then inject into uterus

ICSI (intracytoplasmic sperm ijection) - fertilises eggs. Use if motility issues, low sperm count or other sperm issues

Donor insemination with sperm from another donor

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15
Q

What factors does semen analysis test for?

A

Quantity, quality of semen and sperm

*(Male factor infertility)

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16
Q

What factors can affect sperm quality or quantity?

A 
Hot baths
Tight underwear
Smoking/alcohol
Caffeine
Raised BMI
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17
Q

What results are tested for by semen analysis?

A 
semen volume
semen pH
concentration of sperm
total number of sperm
motility of sperm
vitality of sperm (active sperm)
percentage of normal sperm
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18
Q

What is the difference between cryptozoospermia and azoospermia?

A

cryptozoospermia - very few sperm in semen sample

azoospermia - complete absence of sperm in semen sample

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19
Q

What are pre-testicular causes of infertility?

A

Low testosterone (low LH/FSH causes less testosterone):

  • pathology of pituitary gland/hypothalamus
  • supppression due to stress, chronic conditions or hyperprolactinaemia
  • Kallman syndrome
20
Q

What are the 3 categories of testicular causes of male infertility?

a) Testicular damage
b) Genetic or congenital disorders
c) Post-testicular causes

A

Testicular damage

Genetic or congenital disorders resulting in defective/absent sperm production

Obstruction preventing sperm from being ejaculated (post-testicular cause)

21
Q

What are testicular damage causes of male infertility?

A
  • Infertility
  • Undescended testes
  • Trauma
  • Radiotherapy
  • Chemotherapy
  • Cancer
22
Q

What are genetic/congenital disorders that can cause male infertility?

A

Genetic or congenital disorders resulting in defective/absent sperm production:

  • Klinefelter syndrome
  • Y chromosome deletions
  • Sertoli cell-only syndrome
  • Anorchia (absent testes)
23
Q

What are post-testicular causes of male infertility?

A

Obstruction preventing sperm being ejaculated can be caused by:

  • Damage to testicle/vas deferences from trauma, surgery or cancer
  • Ejaculatory duct obstruction
  • Retrograde ejaculation
  • Scarring from epididmyitis - caused by chlamydia
  • Absence of vas deferences (may be associated with CF)
  • Young’s syndrome (obstructive azoospermia, bronchiectasis, rhinosinusitis)
24
Q

What investigations can be done for male infertility?

A

Semen analysis

Further investgations:

  • Hormonal testing - LH, FSH, Testosterone
  • Genetic testing
  • Further imaging - transrectal USS, MRI
  • Vasography - ?obstruction
  • Testicular biopsy
25
Q

How is male infertility managed?

A

Surgical sperm retrieval (if obstruction)

Surgical correction (if obstruction in vas deferens)

Intra-uterine insemination (separate high quality sperm and inject into uterus)

ICSI (intracytoplasmic sperm injection) - inject sperm directly into egg cytoplasm

Donor insemination

26
Q

What is the NHS limitation on IVF?

A

Couples are limited to set number of cycles funded by NHS

Very expensive and complicated process

27
Q

What is the success rate of IVF at producing a live birth?

A

25-30% per attempt

28
Q

What are the steps of IVF?

A 
Suppress natural menstrual cycle
Ovarian stimulation
Oocyte collection
Insemination/ICSI
Embryo culture
Embryo transfer
Pregnancy test + USS
29
Q

In IVF, how is the natural menstrual cycle suppressed?

A

GnRH agonist or GnRH antagonist

*stop LH/FSH causing follicles to be released without opportunity to collect them

30
Q

In IVF, how are the ovaries stimulated?

A

Subcut injections of FSH -> wait for follicles to develop -> stop FSH -> inject hCG (mimics LH, stimulates maturation of follicles)

*FSH stimulates development of follicles. Monitored with transvaginal USS

31
Q

What is the role of hCG injection in IVG?

A

Trigger injection - mimics LH and stimulates final maturation of follicles -> ready for collection!

32
Q

In IVF, how are oocytes collected?

A

Transvaginal USS guided

Oocytes collected from ovaries using needle through vaginal wall into ovary to aspirate fluid from each follicle

Fluid contains mature oocytes from the follicles

Fluid from follicles then examined under microscope for oocytes

33
Q

In IVF, how is oocyte insemination performed?

How is this different from ICSI?

A

Frozen or active sperm sample mixed with egg in culture medium

Thousands of sperm combined with egg oocytes for fertilisation to occur

ICSI used for male factor infertility - highest quality sperm isolated and injected directly into cytoplasm of the egg

34
Q

During oocyte insemination in IVF, why must thousands of sperm need to be mixed with each oocyte?

A

To produce enough enzymes (hyaluronic acid) for one sperm to penetrate the corona radiata and zona pellucida and fertilise the egg.

35
Q

In IVF, when are the embryos cultured until?

A

Fertilised eggs incubated over 2-5 days (until blastocyst stage)

36
Q

In IVF, how does embryo transfer occur?

A

after 2-5 days, highest quality embryo selected for transfer.

Catheter inserted into uterus via cervix

Only single embryo transferred (maybe 2 if older women, 35 yo+)

Remaining embryos can be frozen for future attempts at transfer!

37
Q

After embryo transferred into woman’s uterus in IVF, what test must be performed?

A

Pregnancy test

38
Q

What hormone must be given post-implantation in IVF and why?

A

Progesterone (Vaginal suppository) - mimics progesterone that would be released by corpus luteum during typical pregnancy.

Given from oocyte collection until 8-10 weeks gestation only

*After 10 weeks, placenta takes over production of progesterone

39
Q

What imaging investigation must be carried out to check if IVF has worked?

A

USS early in pregnancy (around 7 weeks)

*check for fetal heartbeat, rule out miscarriage or ectopic pregnancy

40
Q

What are complications of IVF?

A

Main complications:

  • Failure
  • Multiple pregnancy
  • Ectopic pregancy
  • Ovarian hyperstimulation syndrome (hCG)

Small risk of:

  • Pain
  • Bleeding
  • Pelvic infection
  • Damage to bladder or bowel
41
Q

What is a major complication of giving hCG during IVF treatment?

A

Ovarian hyperstimulation syndrome

  • check renin level as activation of RAAS system occurs
  • VEGF is stimulated from granulosa cells of follicles by hCG injection - fluid leaks from capillaries -oedema, ascites, hypovolaemia.
42
Q

What are risk factors for ovarian hyperstimulation syndrome?

A 
Younger age
Lower BMI
Raised anti-Mullerian hormone
Higher antral follicle count
PCOS
Raised oestrogen levels during ovarian stimulation
43
Q

How are women at risk of developing ovarian hyperstimulation syndrome assessed?

A

During IVF stimulation with gonadotrophins (LH/FSH - these cause VEGF release from follicles), they are monitored for following:

  • Serum oestrogen (higher = higher risk)
  • USS monitor of follicles (higher number + larger size = higher risk
44
Q

How may women at risk of developing ovarian hyperstimulation syndrome be managed before they develop it?

A

Use of GnRH antagonist protocol (instead of GnRH agonist)

Lower doses of gonadotrophins

Lower doses of hCG injection

Alternatives to hCG injection (i.e. GnRH agonist or LH)

45
Q

What are features of ovarian hyperstimulation syndrome?

A

Early OHSS - 7 days of hCG injection
Late OHSS - 10 days+ after hCG
injection

Signs/symptoms

  • Abdo pain/bloating
  • Nausea + vomiting
  • Diarrhoea
  • Hypotension (VEGF/Renin)
  • Hypovolaemia (VEGF)
  • Ascites
  • Pleural effusion
  • Renal failure
  • Peritonitis (from rupturing follicles releasing blood)
  • Prothrombotic state (DVT/PE risk)
46
Q

How is ovarian hyperstimulation managed in the clinical setting?

A

Supportive treatment (with treatment of complications as well)

  • Oral fluids
  • Monitor urine output
  • LMWH (prevent VTE)
  • Ascitic fluid removal (paracentesis)
  • IV colloids (human albumin solution)

*Monitor haematocrit to assess volume of fluid in intravascular space. Raised haematocrit means less fluid in intravascular space, therefore dehydration!!!!!!!!!!!!!!

Obs & Gynae (13 decks)

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