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Reproductive > Infertility/subfertility > Flashcards

Infertility/subfertility Flashcards

1
Q

How many couples report infertility problems?

A

1/7

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2
Q

What is the definition of infertility?

A

Inability of a couple to conceive after 12 months of regular intercourse without use of contraception

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3
Q

What percentage of couples in general population manage to conceive within one year if the women is under 40 and they do not use contraception and have regular intercourse?

A

80%

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4
Q

80% of couples in general population will conceive within 1 year if:

A

Woman is aged under 40

They do not use contraception and have regular intercourse

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5
Q

What are the main questions about why couples might not be able to conceive?

A

Are eggs available?
Is sperm available?
Can they meet?
Can embryo implant?

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6
Q

What is asked about in female history re: fertility?

A 
Duration of infertility
Previous contraception
Fertility in previous relationships
Previous pregnancies and complications
Menstrual history
Medical and surgical history
Sexual history
Previous investigations
Psychological assessment
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7
Q

What is check in a female examination re: fetility?

A 
Weight/height
BMI
Fat and hair distribution
Galactorrhoea
Abdo exam
Pelvic exam
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8
Q

What can a cause of hirsutism be?

A

PCOS (excessive androgen levels)

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9
Q

What is the clinical scoring system for measuring hirsutism in women?

A

Ferriman Gallwey Score

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10
Q

What biochemicals are measured to check for hirsutism?

A

Testosterone
Dehydroeplandrosterone sulphate (DHEAS)
Progesterone

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11
Q

What is acanthosis nigricans a sign of?

A

Androgen excess

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12
Q

What are you looking for in a pelvic examination?

A 
Masses
Pelvic distortion
Tenderness
Vaginal septum
Cervical abnormalities
Fibroids
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13
Q

What are the 3 types of fibroid?

A

Submucous
Intramural
Subserosal

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14
Q

What are the signs of fibroids?

A

Pressure symptoms
Period problems
Infertility

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15
Q

What are baseline investigations in a female for infertility?

A

Rubella.immunity
Chlamydia
TSH
Mid luteal progesterone (if periods regular)
Day 1-5 FSH, LH, PRL, TSH, testosterone (periods irregular)

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16
Q

What is the baseline investigation in a male for infertility?

A

Semen analysis

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17
Q

What are investigations that can be done at fertility clinic?

A 
Pelvic USS
Physical exam
Testing for ovulation
Semen analysis repeat
Tubal patency test
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18
Q

How can ovulation be assessed?

A

Regular monthly menstrual cycles - likely ovulating
Serum progesterone blood test in mid-luteal phase of cycle (day 21) to confirm ovulation

Irregular monthly menstrual cycles - same test later
Blood test to measure serum gonadotrophins (FSH and LH)

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19
Q

What is the screening for tubal occlusion in investigating infertility?

A

Hysterosalpingography (HSG)

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20
Q

What is a more invasive test to check for tubal occlusion in suspected infertility?

A

Laparoscopy

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21
Q

What is asked about in male history re: fertility?

A

Developmental: testicular descent, change of shaving frequency, loss of body hair
Infections: mumps, STIs
Surgical: varicocele repair, vasectomy
Previous fertility
Drugs/environmental: smoking, alcohol, anabolic steroids, chemo, radiation, drugs
Sexual history: libido, frequency of intercourse, previous fetility assessment
Chronic mental illness

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22
Q

What is examined in males re: infertility?

A

Weight/height
BMI
Fat and hair distribution (hypoandrogenism)
Abdo and inguinal exam
Genital exam: epididymis, testes, gas deferens, varicocele

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23
Q

What can cause epididymitis?

A

STIs:

  • Chlamydia trachomatis
  • Gonorrhoea
24
Q

What is a varicocele?

A

Dilatation of pampiniform plexus of the spermic veins in the scrotum

25
Q

What are signs of varicocele and presumptive infertility?

A

Low sperm concentration and abnormal

26
Q

What is one of the most common causes of primary hypogonadism with impaired spermatogenesis and testosterone deficiency?

A

Klinefelter syndrome

27
Q

What is CBAVD?

A

Congenital bilateral absence of the vas deferens

28
Q

What can cause CBAVD?

A

Cystic fibrosis mutations

29
Q

When would you refer a couple to infertility clinic?

A 
1 year of trying
Period irregularities
PMH
Testicular problems
Abnormal tests
HIV/Hep B
Anxiety
Age:
- <35 after 1yr
- 35-45 after 6mo
- >45 (little can be offered)
30
Q

What are the 3 classes of ovulatory disorder?

A

Group I: hypothalamic pituitary failure
Group II: hypothalamic-pituitary-ovarian dysfunction
Group III: ovarian failure

31
Q

What is included in Group I hypothalamic pituitary failure?

A

Hypothalamic amenorrhoea

Hypogonadotrophic hypogonadism

32
Q

How can women in Group I ovulatory disorders improve their chances of regular ovulation, conception and uncomplicated pregnancy?

A

Increasing their body weight if BMI less than 19

Moderating exercise levels

33
Q

What can you offer women with Group I ovulation disorders to induce ovulation?

A

Gonadotrophin-releasing hormone

Gonadotrophins with LH activity

34
Q

What are signs/signs of PCOS?

A

Androgen excess
Infrequent periods
Polycystic ovaries

35
Q

How can you tell there is androgen excess?

A

Clinical: hirsutism
Biochemical: testosterone levels

36
Q

What is the management of ovulatory disorders?

A

Treat underlying cause
Weight loss/gain
Ovulation induction: clomifene or gonadotrophins

37
Q

What drugs can be used to induce ovulation?

A

Clomifene
Gonadotrophins
GnRH

38
Q

What is the action of clomifene?

A

Binds to estrogen receptors - stimulates gonadotrophin release
And
Direct effect on ovaries

39
Q

How is clomifene use monitored?

A

Follicle scanning in 1st cycle

May need dose adjustment

40
Q

What are side effects of clomifene?

A

Vasomotor

Visual

41
Q

When are gonadotrophins used for ovulation?

A

No ovulation with clomifene

Ovulation but no pregnancy

42
Q

How are gonadotrophins given to induce ovulation?

A

FSH by injection

43
Q

What are hydrosalpinges?

A

The fallopian tube is blocked and fills with serous or clear fluid near the ovary

44
Q

What should women with hydrosalpinges be offered before IVF?

A

Salpingectomy

45
Q

What are options for male infertility/subfertility?

A

IVF
Intra-uterine insemination
Surgery: reversal vasectomy/surgical sperm retrieval
Donor insemination

46
Q

What are the two types of azoospermia?

A

Testicular

Posr-testicular

47
Q

What are testicular causes of azoospermia?

A

Normagonadotrophic
Hypogonadism
Hypergonadotrophic

48
Q

What are post-testicular causes of azoospermia?

A

Iatrogenic
Congenital
Infective

49
Q

What are investigations for azoospermia?

A

History and exam
FSH, LH, testosterone, karyotype, PRL
CF screen

50
Q

When should you not offer ovarian stimulation agents (clomifene)?

A

Women with unexplained infertility

51
Q

How long should women with unexplained infertility try to conceive before offering IVF treatment?

A

2 years

52
Q

What is ICSI?

A

Intracytoplasmic sperm injection (ICSI)
Injection of mature eggs with single sperm
Incubation overnight
Embryo transferred to uterine cavity

53
Q

24yr woman present with 18mo history of amenorrhoea since stopping OCP 28mo ago to try for pregnancy. BMI is 31. What is the most appropriate next step investigation?

A

Hormone profile to check SHBG, free testosterone and FSH and LH and prolactin

54
Q

24yr woman present with 18mo history of amenorrhoea since stopping OCP 28mo ago to try for pregnancy. BMI is 31. What is the most likely diagnosis?

  • Anorexia nervosa
  • Hyperprolactinaemia
  • Hypogonadotrophic hypogonadism
  • PCOS
  • Premature ovarian failure
A

PCOS

55
Q

Which of the following is correct with regards to PCOS?

  • A high FSH and LH level
  • Affected women are very fertiile
  • Affects >50% infertile pop
  • Metformin contraindicated
  • US appearance of large number of follicles arranged peripherally in the ovarian cortex of large volume ovaries
A

US appearance of large number of follicles arranged peripherally in the ovarian cortex of large volume ovaries

56
Q

28yr woman with PCOS and primary subfertility of 4yra attends fertility clinic. Her cycles are irregular and she is currently on Metformin, helping her weight control (BMI 28), she is amenorrheic. Keen to start fertility treatment. A hysterosalpingogram confirmed bilaterally patent tubes.
What is most appropriate initial mangemt of her subfertilit?
- Advice on weight loss and review 6mo
- Intrauterine insemination for six cycles
- Laparoscopic diathermy to ovaries
- Ovulation induction with clomifene 50mg for 6mo
- Recommend one cycle IVF treatment

A

Ovulation induction with clomifene

Reproductive (20 decks)

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