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Obstetrics + gynaecology > Infertility + sexual dysfunction > Flashcards

Infertility + sexual dysfunction Flashcards

1
Q

Outline the process of conception

A
  • Sperm deposited in vagina - travel - a few reach the fallopian tube and swim to the oocyte (within 30m of ovulation)
  • Sperm surround zona pellucida- acrosome reaction to lose plasma membrane - penetrate oocyte
  • 2nd meiotic division of ovum occurs, sperm + ovum haploid nuclei combine, 46 chromosomes
  • Fertilised egg travels along tube by peristalsis + cilia
  • Cleavage of zygote - morula - fluid filled cavity develops - blastocyst
  • Embryonic pole of blastocyst attaches to endometrium, cut-trophoblast destroys endometrial cells, endometrial cells become large + pale (decidual reaction)
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2
Q

Define infertility

A

No conception after 12 months in a couple having regular unprotected coitus (every 2-3 days)

  • Primary - no previous pregnancy or live birth
  • Secondary - no conception after a previous pregnancy even if it ended in miscarriage/ectopic/TOP
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3
Q

Define subfertility

A

A delay in conceiving, usually due a problem in one partner that can be compensated for by higher function in the other

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4
Q

RF for infertility

A
  • Female age >35, in males age less relevant but older=more sperm abnormalities
  • Serious systemic illness
  • Inadequate nutrition
  • Excessive exercise
  • Stress
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5
Q

What are the causes of infertility?

A
  • Ovulatory - oligo/amenorrhoea. hypogonadotrophic when pituitary hormones fail (e.g. after radiotherapy or Kallman’s syndrome), PCOS, premature ovarian failure (depletion of follicles before age 40), hyperprolactinaemia (e.g. pituitary micro adenomas). 20%
  • Tubal factors - block access to uterus. Infections (usually C trachomatis causing pyosalpinx/hydrosalpinx), congenital anomalies (rare), peritubal adhesions (appendicitis, IBD, tho these usually aren’t in the lumen). 15%
  • Uterine factors - make implantation more difficult. Submucosal fibroids, Asherman syndrome (adhesions from infection/surgery), endometriosis, congenital like intrauterine septum.
  • Cervical factors - hostile mucus (infection, anti-sperm antibodies), dyspareunia
  • Male factors - poor quality sperm. 30%
  • Unexplained - 25%
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6
Q

How do you assess a couple presenting with fertility problems?

A
  • See together
  • Reassurance that 84% conceive in 1y and 93% by 3y, encourage regular intercourse
  • History: h/o contraception, length of trying, previous conceptions of either partner (inc past relationships), complications with pregnancies, full gynae hx inc STIs, general PMH, h/o undescended testes or orchidopexy in the man
  • Examination: BMI, hirsute features, don’t normally need further exam
  • Investigations: considered after 12m
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7
Q

What investigations are indicated for fertility problems?

A
  • Female: mid-luteal phase progesterone (7d before expected period), chlamydia screen
  • If indicated may also check FSH+LH, TFTs, prolactin; in secondary care do tubal patency testing using US with contrast, or if h/o PID/endo/prev ectopic do a diagnostic laparoscopy with dye
  • Male: semen analysis, at least 2d of abstinence but no more than 7d, take to lab within 1h, needs to be complete. If 1st normal can assume is not a male problem; also Chlamydia screen
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8
Q

General management of infertility

A
  • Folic acid
  • Screen for cervical + rubella
  • Stress management, counselling
  • Smoking cessation, weight loss, alcohol (ideally none but incomplete evidence)
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9
Q

Medical management of infertility

A
  • Clomiphene citrate - induces induction in anovulation by opposing oestrogen, given on day 2-6 of cycle. Well-tolerated but s/e may include PCOS cysts enlarging, tender breasts, cholestatic jaundice or abdo distension
  • Gonadotrophins - FSH or FSH+LH. Can give to woman, or to man if has hypogonadotrophic hypogonadism. CI in breast/ovarian/uterus/pituitary tumours, s/e are tender breasts and OHSS and PV discharge/bleeding
  • Dopamine agonists: e.g. cabergoline
  • Metformin in PCOS to reduce insulin resistance
  • Treat endometriosis with COCP, GnRH agonist, medroxyprogesterone - but this suppresses ovarian function
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10
Q

Surgical management of infertility

A
  • Ovarian drilling

* Tubal surgery - resection, adhesiolysis (for endometriosis)

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11
Q

What is assisted conception?

A

Conception achieved through means other than coitus. Encompasses intrauterine insemination, IVF, ICSI, donor insemination, oocyte donation and embryo donation

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12
Q

Intrauterine insemination

A
  • Sperm put in uterus at the time of ovulation - more chance of reaching FT for fertilisation
  • Good for cervical cause as bypasses this
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13
Q

In vitro fertilisation

A
  • Eggs retrieved, mixed with sperm, incubated, embryo injected into uterus
  • Good for backed tubes, men with minor sub fertility or unexplained cause
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14
Q

Intracytoplasmic sperm injection

A
  • Inject individual sperm into an egg to bypass natural barriers to fertilisation, then embryo put into uterus
  • Useful when there’s a low sperm count or erectile/ejaculatory dysfunction
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15
Q

Donor insemination

A
  • IUI with donor sperm

* E.g. female same sex relationships, men with very few sperm or infectious disease

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16
Q

Oocyte and embryo donation

A
  • Oocyte: stimulate + collect donor egg, fertilised by recipient sperm, transferred to recipient uterus after it has been hormonally prepared. Good for ovarian failure, Turner syndrome, b/l oophorectomy
  • Embryo: donation by couples who’ve had successful IVF/ICSI and have embryos left over
17
Q

What is ovarian hyperstimulation syndrome and why does it happen?

A

A complication of gonadotrophic drugs, particularly from IVF.

Drugs stimulate ovaries - excessive response - release oestrogens + VEGF - ovaries enlarge - fluid shift into 3rd space - ascites, effusions, oliguria

18
Q

How does ovarian hyperstimulation syndrome present?

A

Abdo swelling/pain, vomiting
Extreme thirst, VTE, dehydration, pleural effusion
Can lead to ARDS and renal failure

19
Q

What is the management for ovarian hyperstimulation syndrome?

A

Monitor U+E and LFTs
ACEi and indomethacin may help
Eventually the ovary cysts resorb and ovary goes back to normal size

20
Q

Dyspareunia

A
  • Superficial: pain on entry. Causes include infection in vulva/vagina, narrowed intraoitus (e.g. congenital, excess suturing post-episiotomy), menopausal (atrophic vaginitis, lichen sclerosus), vulvodynia, functional (lack of lubrication as not enough stimulation or emotional cause of this)
  • Deep: pain on deep penetration. Causes include PID, retroverted uterus with ovary prolapse into PoD, endometriosis, neoplasia of cervix/vagina, post-op scarring, foreign bodies
  • Apareunia: unable to have intercourse e.g. imperforate hymen or congenital vaginal absence
21
Q

Vaginismus

A

Muscle spasm (pelvic floor + thigh adductors) causing pain on attempted penetration

  • Primary - fear
  • Secondary - past experience of pain on intercourse or assault or a difficult delivery or post-surgery
22
Q

Loss of libido

A
  • Can occur in either sex
  • Repression of sexual thoughts, cultural - if always been like this
  • New onset: relationship issues, major life events, depression, endocrine problems, pain, menopause, stress, drugs like anti-depressants/cytotoxics/anti-oestrogens/sedatives/narcotics
23
Q

What is the physiology of male sexual function?

A

Erection - vasoconstriction via PSNS
Ejaculation + orgasm - vasodilation by SNS (adrenergic)
Pudendal n opens the external sphincter, bulbocavernosus + ischiorectal muscles contract

24
Q

Erectile dysfunction (impotence)

A
  • Causes: vessel/nerve damage (e.g. DM), neurological (MS, SC injury, prostate injury), hyperprolactinaemia, psychogenic (stress, depression), drugs (anti-hypertensives, diuretics, antidepressants, alcohol)
  • M: sildenafil (Viagara-potentiates effect of NO on vascular smooth muscle), injection of prostaglandin E1, counselling/sex therapy
25
Q

Ejaculatory dysfunction

A

May be premature, retrograde or absent

  • Absent/premature more common in younger
  • Retrograde usually an organic cause e.g. post-prostate surgery
26
Q

Premature ovarian failure

A

Onset of menopausal sx + elevated gondaotrophins <40y

Causes: idiopathic, chemo, autoimmune, radiation

27
Q

What is the most reliable test to confirm ovulation?

A

Day 21 progesterone (peaks 7d after ovulation, obv if not 28d cycle do 7d prior to expected next period as luteal phase is always the same)

Obstetrics + gynaecology (13 decks)

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