Infertility - Women Flashcards
Infertility - management Common fertility disorders
When should a couple be referred to a fertility clinic? [6]
Only if they’re been trying unsuccessfully for at least 12 months or
Have other problems such as:
- Irregular Periods
- Relevant PMH
- Testicular Problems
- HIV/HEP B
- (performance) Anxiety
List some of the major causes for Female Infertility? [6]
- Ovulatory Disorders
- Fibroids
- Endometriosis
- Tumours: androgen-secreting adrenal tumor, prolactinoma
- Tubal Block
- Unexplained
What are the 3 categories of ovulatory disorders? [WHO]
Group 1 = Hypothalamic-Pituitary failure
Group 2 = Hypothalamic-Pit-Ovarian dysfunction (mainly PCOS)
Group 3 = Ovarian Failure
How would we treat someone with a Group 1 Ovulatory Disorder? [2]
Optimise their BMI - increase and/or moderate exercise if very active
Ovulation induction with GnRH
Dx: PCOS - 3 main criteria in Rotterdam criteria
What makes a positive diagnosis?
What is important to remember about diagnosis of PCOS?
The Rotterdam Criteria. 2 out of 3 is +ve: - Infrequent Periods - Androgen excess - Polycystic ovaries on ultrasound PCOS is a diagnosis of exclusion
What signs would you look for to indicate androgen excess in PCOS? [3]
- Hirsutism
- Acanthosis Nigricans
- Moderately raised testosterone
How do we Rx PCOS? [4]
1) Optimise BMI
2) Ovulation Induction with Clomifene or Gonadotrophins
3) Endometrial protection
4) Hirsutism: spironolactone, elfornithe
How does Clomifene work in ovulation induction?
MOA [3]
Dose and duration
Prime with…?
Antagonises oestrogen receptors –> no -negative feedback –> More Gonadotrophins –> Ovulation
Use 50-150mg on days 2-6,
Prime with progesterone if amenorrhoeic
Side effects of clomiphene
How does this affect clinical mx [1]
Ovarian Hyperstimulation
Multiple Pregnancy
Ovarian cancer
Visual and vasomotor disturbance
Hence why we do Follicle Scanning in the 1st cycle and adjust the dose if required
When would we use Gonadotrophins (FSH injection) to induce ovulation instead of clomifene? [1]
How many cycles of these injections? [1]
If clomifene produces no ovulation or ovulation but no pregnancy
Up to 3-6 cycles
How would you spot an androgen-secreting adrenal tumour?
Describe 3 findings on investigation [3]
Describe associated symptoms [2]
Testosterone will be very elevated (much higher than in PCOS)
DHEAS will be raised. Follow up with an Adrenal CT.
Symptoms include Hirsutism and Acanthosis Nigricans
How would we treat a case of unexplained female infertility?
Don’t do ovulation induction, do IVF
What can cause Tubal block? [5]
- Chlamydia, gonorrhea, PID
- Tumour
- Ectopic surgery, past abdominal surgery
- Sterilization
- Fibroids and endometriosis
What kind of questions would we want to ask a woman when assessing fertility? [8]
- Duration of infertility
- Past Fertility
- Past pregnancies and complications of each
- Past Contraception
- PMH
- Menstrual History
- Sexual History
- Psychological Assessment
What would you assess on exam when thinking of infertility? [5]
Weight, height --> BMI Fat and Hair Distribution (ddx hirsutism of androgen excesss) Galactorrhoea (prolactinoma) Abdo Exam Pelvic Exam for masses or fibroids
What baseline tests can be done in primary care to assess fertility - for both male and female partners [5]
- Rubella immunity
- Chlamydia
- TSH
- Ovulatory function
- Male: semen analysis
Baseline investigations outside a specialist fertility clinic to assess fertility?
How do we test for ovulation? [3]
IF they have regular periods do a Mid-luteal (day 21) phase progesterone 7d before expected period
If irregular, do day 1-5 FSH, LH, PRL, TSH and testosterone.
Do progesterone later in cycle eg 28/35 then repeat weekly subsequently until next menstrual cycle
Once at a fertility clinic we can do futher tests for women, what do these include? [4]
Physical exam
Lab work - ovulatory fxn
Transvaginal US looking for masses, structural abnormalities
Tubal Patency test looking for Tubal Block
2 options - investigation of tubal block
Either with a HyCoSo (Hysterosalpingo-contrast-sonography)
Or Laparoscopy
How does IVF work? [4]
Harvest eggs from ovary
Fertilise with sperm in lab
~5days incubation
Implant embryo using transfer catheter
ICSI is another form of IVF, how does it work? [1]
Injection of a single sperm into mature eggs instead of mixing the two in a lab and allowing for normal fertilisation
What are the referral (to specialist) guidelines - with age as risk factor [3]
<35 yo - refer after 1 year
35-45 - refer after 6m
>45 yo - little can be offered
Definitions: Infertility [2]
Defined as inability of a couple to conceive after 12 months of regular intercourse without use of contraception.
Definitions: Primary infertility
Primary infertility: refers to couples who have not become pregnant after at least 1 year having sex without using birth control methods.
Definitions: Secondary infertility [1]
Secondary infertilityrefers to couples who have been able to get pregnant at least once, but now are unable
Group 1 ovulatory disorders:
Causes [4]
Low body weight, stress, exercise-related amenorrhea
Craniopharyngioma or other tumours affecting hypothalamus
Amenorrhea combined with anosmia – Kallmann’s syndrome
Idiopathic
Group 2 ovulatory disorders:
What are 3 disorders under this category?
Androgen excess
Infrequent periods
Polycystic ovaries (PCOS)
2 differentials for hirsutism secondary to androgen excess
Androgen secreting tumours
Ovarian hyperthecosis
Ix for androgen excess disorders
1 clinical
3 biochemical
1 imaging
Clinical dx - Ferriman Gallwey score
Biochemical measurement of testosterone, DHEAS, 17-OH progesterone
Adrenal CT
Rotterdam Criteria - specific details of:
Oligo/anovulation [2]
Ultrasound findings [2]
Oligo/anovulation
- menstrual cycles >35 days apart with short cycles of <21 days
Ultrasound findings
- 10 small antral follicles in each ovary even if unilateral
Symptoms of virilisation [7]
seen in PCOS
Excess facial and body hair or baldness Acne Deepening of voice Increased muscularity, sex drive Uterine and breast atrophy Clitoral enlargement Amenorrhea
Methods to measure testosterone [3]
Free testosterone
Free androgen index
Bioavailable testosterone
Management of infertility
Anovulation [3]
Tubal disease [2]
Intrauterine adhesions
Anovulation: - weight loss/gain, clomifene, gonadotrophins, laparoscopic ovarian drilling Tubal disease: - tubal catheterization - hysteroscopic cannulation Intrauterine adhesions: - hysteroscopic adenolysis
IVF indications
Tubal disease Male factor subfertility, Endometriosis Anovulation not responding to clomiphene Maternal age Unexplained subfertility >2yrs
