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YEAR 4 REPRO > Infertility (Male and Female) > Flashcards

Infertility (Male and Female) Flashcards

1
Q

Define infertility

A

Inability to conceive after 12 months of regular (once every 2-3 days ) unprotected sexual intercourse

Primary - no pregnancy before
Secondary - children w/ current or previous partner

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2
Q

How does age affect fertility?

A

Decline in oocyte population and eggs inherent quality. Increased risk of spontaenous miscarriage and genetically abnormal offspring

pronounced decline from 37
steep decline after 40

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3
Q

What are causes of infertility?

A

Ovulation defects (25%)
Male factor (30%)
Tubal disease (20%)
Unexplained infertility (25%)

other:
Endometriosis
Uterine factors (abnormalities)
Other

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4
Q

What are causes of anovulation?

A

PCOS
Weight related BMI >30 / <18
Ovarian failure - premature ovarian insufficiency ( secondary cause of this could be a pt on chemo/ radiotherapy)
Hyperprolactinaemia

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5
Q

What is a cause of tubal disease?

A

PID - blocking tube or damaging function of tube

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6
Q

How do you diagnose infertiliy?

A

Diagnosis is one of exclusion

Identify :
1) clear cause
2) possible cause
3) unexplained cause

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7
Q

In a woman with suspected infertility what points do you want to cover in the history and why?

A

1) Age
- oocyte number and quality

2) Duration of fertility

3) Type of infertility
- is it secondary infertility - do the couple independently have children?

4) Menstrual cycle - ovulating?
Flow / pain associuated / IMB / PCB

5) Tubal surgery / PID?
- cause adhesions

6) Menorrhagia / dysmenorrhoea / pelvic pain
- e.g endometriosis

7) hx of pelvic surgery - adhesions

8) Hx of STIs

9) Smoking / alcohol / Drug history / PMHX

10) Sex - how often, erectile dysfunction / stress etc

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8
Q

What are you looking for on examination of a woman w/ possible infertility ? Why?

A

1) BMI
-Low or high can cause infertiliy e.g. low BMI and extreme exercise causing 2 amenorrhea and anovualtion.

2) Body hair distribution
- look for signs of hyperandrogenism -PCOS

3) Galactorrhoea
- breast exam sign of prolactinaemia due to pituitary tumour

4) Secondary sexual characteristics
- primary or secondary cause of amenorrhorea

5) Pelvic examination
- structural abnormalities
- fixed or tender uterus (another card for details of this)

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9
Q

You are examining a woman with suspected infertility.
1) Walk through how and what will examine
2) What bedside investigations might you do while there?

A

1)
- Examine vulva, vagina and cervix with speculum - looking for structural abnormalities
- Do : bimanual pelvic examination looking for:
fixed (fixed retroverted uterus - endometriosis / adhesions), tender uterus or masses (fibroids)

2) While have your speculum do:
-genital swabs (HVS and chlaymidia)
- cervical smear if not done

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10
Q

Seeing a male pt for infertility
What do you want to cover in the history and why?

A

1) general health

2) alcohol and smoking

3) Previous surgery
- inguinal hernia, undescended testes

4) Previous infection
- TB, mumps as an adult

5) Sexual
- ejaculatory / erectile dysfunction
- frequency of sex

6) Drug hx / PMHx

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11
Q

What might you to include when examining a male pt for infertility?

A
  • normla secondary sexual characterisics
  • gynaemastia?
    • Scrotum (look for varicocele)
    • testicular size
    • testicular positon (undescended)
    • Prostate - rectal exam for chronic infection prostatitis
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12
Q

How can you divide causes of male factor infertility?

A

Pre-testicular
Testicular
Post testicular

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13
Q

What are some pre-testicular causes of male infertility?

A

Pathophysiology: Testosterone is needed for sperm (HPA axis controls testosterone) Having LOW LH and FSH (hypogonadoptrophic hypogonadism) and LOW TESTOSTERONE can be due to:

  • Pituitary gland or hypothalamus pathology
  • Suppression - stress or chronic conditions e..g hyperprolactintaemia
  • Kallman syndrome
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14
Q

What are some testicular causes of male infertility?

A

Testicular damage from:
* Mumps
* Undescended testes
* Trauma
* Radiotherapy
* Chemotherapy
* Cancer

Genetic / congenital = defective / absent sperm production:
* Klinefelter syndrome
* Y chromosome deletions
* Sertoli cell-only syndrome
* Anorchia (absent testes)

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15
Q

What are some testicular causes of male infertility?

A

Obstruction preventing sperm being ejaculated can be caused by:

  • Damage to the testicle or vas deferens from trauma, surgery or cancer
  • Ejaculatory duct obstruction
  • Retrograde ejaculation
  • Scarring from epididymitis, for example, caused by chlamydia
  • Absence of the vas deferens (may be associated with cystic fibrosis)
  • Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)
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16
Q

How would you investigate female infertility?

A

Baseline tests:
Bedside
* Chlaymidia screening (HIV Hep B, C need to be tested beofre see specialist)

Bloods / lab:
* Baseline hormonal profile: Day 2 FSH and LH
* TSH
* Prolactin
* Testosterone levels
* anti-mullerian hormone
* rubella status (vaccinate if not immune)
* Mid luteal phase progesterone to confirm ovualting (day 21 or 7 days before next expected period)

Imaging:
* TVUS - adnexal massesm fibroids, endometrial popyls, PCOS
* Hysteroscopy for uterine cavity abnromalities
* Test of tubal patency (will expand later slides)

17
Q

What tests would you do to test tubal patency in a woman with infertility?

A

Hsyterosalpingography (HSG)
* xray imaging and contrast injected through cannuala in cervix to show uterine anatomy and tubal patency
* SE: period like cramps and tubal spasm
* caution: do once chlyamdia swabs -ve and give azithromycin 1g PO

Diagnostic laparoscopy and dye
* day case
* gold standard for tubal patency
* dye injecte thorugh cervix while tubes visualised with laproscope.
* advantage: can treat pelvic pathology at the same time

18
Q

You are going to test tubal patency of a woman with infertility.

  1. When would diagnositc laparoscopy and dye be first line?
A
  1. If strong suspicion of tubal abnormality e.g. Hx of PID, endometriosis/ previous surgery

Otherwise: would be second line and done is the HSG (hysterosalpingography) abnormal

19
Q

What investigations would you do for a man being investigated dor infertility?

A
  • Semen analysis x 2

Lab:
* FSH (plasma FSH raised in testicular failure)
* LH (+testosterone if suspect androgen insufficiency)
* Testosterone
* Genetic testing (karyotype to exclude 47 xxy and cystic fibrosis screen)

Imaging
* transrectal US seminal vesicles , prostate (if aspermia or low sperm count)
* Vasography, which involves injecting contrast into the vas deferens and performing xray to assess for obstruction

other
* Testicular biopsy

20
Q

What are normal values of sperm analysis according to WHO?

A
  • Semen volume (more than 1.5ml)
  • Semen pH (greater than 7.2)
  • Concentration of sperm (more than 15 million per ml)
  • Total number of sperm (more than 39 million per sample)
  • Motility of sperm (more than 40% of sperm are mobile)
  • Vitality of sperm (more than 58% of sperm are active)
  • Percentage of normal sperm (more than 4%)
21
Q

When testing sperm for infertility the results are below normal range. What shoud you do?

A

Borderline:
* repeat in 3 motnhs

Abnormal:
* repeat 2-4 weeks

Lifestyle changes, mulitvitamin with selenium, zinc and vitamin C

22
Q

What advice should men be given before providing a sample of sperm?

A
  • Abstain from ejaculation for at least 3 days and at most 7 days
  • Avoid hot baths, sauna and tight underwear during the lead up to providing a sample
  • Attempt to catch the full sample
  • Deliver the sample to the lab within 1 hour of ejaculation
  • Keep the sample warm (e.g. in underwear) before delivery
23
Q

What factors affect sperm quality and quantity?

A

lifestyle:

  • Hot baths
  • Tight underwear
  • Smoking
  • Alcohol
  • Raised BMI
  • Caffeine
24
Q

What are different results you can get when examaining semen?

A
  • Polyspermia- lots of perm (more than 250 million per ml).
  • Normospermia - normal characteristics of the sperm
  • Oligospermia- reduced number of sperm. it is classified as:
    1. Mild oligospermia (10 to 15 million / ml)
    2. Moderate oligospermia (5 to 10 million / ml)
    3. Severe oligospermia (less than 5 million / ml)
  • Cryptozoospermia-very few sperm in the semen sample (less than 1 million / ml).
  • Azoospermia - absence of sperm
25
Q

How would you manage male factor infertility?

A

from the Lecture (Z2F has more options)
* IVF
* Intracytoplasmic sperm injection (ICSI) involves injecting sperm directly into the cytoplasm of an egg
* Donor insemination - aspermia

26
Q

What is lifestyle modification for subfertlilty?

A

Directed at cause, the couple should both:
* lose or gain weight to a normal BMI
* healthy diet
* stop smoking / recreational drugs
* reduce alcohol to below recommended limits
* regular exercise
* folic acid (woman)
* sex every 2-3 days (avoid timed as stressful)
* avoid ovulation montiors no evidence helps and if time to day of ovulation can be too late.

27
Q

What is the treatment of infertility if anovulation is the cause ?

A

Depends on cause - trying to induce ovulation

  • Clomifene citrate 50 mg day 2-6 of cycle. anti-oestrogen so increases FSH
  • Gonadotrophins - for clomifene resistant PCOS, injected, US monitoring
  • Dopamine agonists for women with hyperprolactinameia
  • weight loss/ gain
  • Egg donation if primary ovarian insufficiency
28
Q

How would you treat infertility if due to tubal disease?

A

Surgery
* tubal reconstructive surgery at specialist centres

  • IVF
29
Q

What are some indications for IVF?

A

tubal disease
male factor
endometriosis
anovulation not respoinding to clomifene
maternal age cause
unexplained unfertility > 2 yrs

30
Q

Testing for female subfertility what would the followig results suggest?

  1. high FSH
  2. High LH
  3. Rise in progesterone day 21
  4. high antimullerian hormone level
A
  1. high FSH
    * poor ovarian reserve. the pituitary gland is producing extra FSH to stimulate follicular development
  2. High LH
    * suggest polycystic ovarian syndrome (PCOS).
  3. Rise in progesterone day 21
    * indicates that ovulation has occurred, and the corpus luteum has formed and started secreting progesterone.
  4. high antimullerian hormone level
    * (measure at any time during the cycle) the most accurate marker of ovarian reserve. Released by granulosa cells in the follicles and falls as the eggs are depleted. high level = good ovarian reserve.
31
Q

What is Ovarian hyperstimulation syndrome (OHSS)?

A

complication of ovarian stimulation during IVF infertility treatment.

It is associated with the use of human chorionic gonadotropin (hCG) to mature the follicles during the final steps of ovarian stimulation.

32
Q

Pathophysiology of ovarian hyperstimulation syndrome?

A
  • Gonadotrophins (FSH and LH) used to develop multiple follices.
  • OHSS is triggered by “trigger injection” of hCG injection 36 hours beofre oocyte collection
  • hCG stimulates the release of vascular endothelial growth factor (VEGF) from granulosa cells of follicles
  • this increase vascular permeability - fluid leaks from capillaries
  • fluid moves from intravascual space -> extravascular space
  • causes oedema, ascites and hypovolaemia
  • RAAS is activate - pts get raised renin (correlates with severity)
33
Q

What are RF for ovarian hyperstimultion syndrome?

A
  • Younger age
  • Lower BMI
  • Raised anti-Müllerian hormone
  • Higher antral follicle count
  • Polycystic ovarian syndrome
  • Raised oestrogen levels during ovarian stimulation
    *
34
Q

How do you prevent ovarian hyperstimulation syndrome?

A

During stimulation with gonadotrophins, they are monitored with:

  • Serum oestrogen levels (higher levels indicate a higher risk)
  • Ultrasound monitor of the follicles (higher number and larger size indicate a higher risk)

higher risk women:
* Use of the GnRH antagonist protocol (rather than the GnRH agonist protocol)
* Lower doses of gonadotrophins
* Lower dose of the hCG injection
* Alternatives to the hCG injection (i.e. a GnRH agonist or LH)

35
Q

What are features of ovarian hypserstimulation syndrome?

A

Early OHSS within 7 days of the hCG injection.
Late OHSS presents from 10 days onwards.

  • Abdominal pain and bloating
  • Nausea and vomiting
  • Diarrhoea
  • Hypotension
  • Hypovolaemia
  • Ascites
  • Pleural effusions
  • Renal failure
  • Peritonitis from rupturing follicles releasing blood
  • Prothrombotic state (risk of DVT and PE)
36
Q

How do you grade severity of ovarian hyperstimulation syndrome?

A
  • Mild: Abdominal pain and bloating
  • Moderate: Nausea and vomiting with ascites seen on ultrasound
  • Severe: Ascites, low urine output (oliguria), low serum albumin, high potassium and raised haematocrit (>45%)
  • Critical: Tense ascites, no urine output (anuria), thromboembolism and acute respiratory distress syndrome (ARDS)
37
Q

How do you manage ovarian hyperstimulation syndrome?

A
  • Oral fluids
  • Monitoring of urine output
  • Low molecular weight heparin (to prevent thromboembolism)
  • Ascitic fluid removal (paracentesis) if required
  • IV colloids (e.g. human albumin solution)

mild / moderate - outpatient
critical - ICU

YEAR 4 REPRO (26 decks)

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