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Infertility - Women Flashcards

Infertility - management Common fertility disorders

1
Q

When should a couple be referred to a fertility clinic? [6]

A

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
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2
Q

List some of the major causes for Female Infertility? [6]

A
  • Ovulatory Disorders
  • Fibroids
  • Endometriosis
  • Tumours: androgen-secreting adrenal tumor, prolactinoma
  • Tubal Block
  • Unexplained
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3
Q

What are the 3 categories of ovulatory disorders? [WHO]

A

Group 1 = Hypothalamic-Pituitary failure
Group 2 = Hypothalamic-Pit-Ovarian dysfunction (mainly PCOS)
Group 3 = Ovarian Failure

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4
Q

How would we treat someone with a Group 1 Ovulatory Disorder? [2]

A

Optimise their BMI - increase and/or moderate exercise if very active
Ovulation induction with GnRH

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5
Q

Dx: PCOS - 3 main criteria in Rotterdam criteria
What makes a positive diagnosis?
What is important to remember about diagnosis of PCOS?

A 
The Rotterdam Criteria. 
2 out of 3 is +ve:
- Infrequent Periods 
- Androgen excess
- Polycystic ovaries on ultrasound 
PCOS is a diagnosis of exclusion
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6
Q

What signs would you look for to indicate androgen excess in PCOS? [3]

A
  • Hirsutism
  • Acanthosis Nigricans
  • Moderately raised testosterone
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7
Q

How do we Rx PCOS? [4]

A

1) Optimise BMI
2) Ovulation Induction with Clomifene or Gonadotrophins
3) Endometrial protection
4) Hirsutism: spironolactone, elfornithe

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8
Q

How does Clomifene work in ovulation induction?
MOA [3]
Dose and duration
Prime with…?

A

Antagonises oestrogen receptors –> no -negative feedback –> More Gonadotrophins –> Ovulation

Use 50-150mg on days 2-6,

Prime with progesterone if amenorrhoeic

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9
Q

Side effects of clomiphene

How does this affect clinical mx [1]

A

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

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10
Q

When would we use Gonadotrophins (FSH injection) to induce ovulation instead of clomifene? [1]
How many cycles of these injections? [1]

A

If clomifene produces no ovulation or ovulation but no pregnancy

Up to 3-6 cycles

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11
Q

How would you spot an androgen-secreting adrenal tumour?
Describe 3 findings on investigation [3]
Describe associated symptoms [2]

A

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

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12
Q

How would we treat a case of unexplained female infertility?

A

Don’t do ovulation induction, do IVF

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13
Q

What can cause Tubal block? [5]

A
  • Chlamydia, gonorrhea, PID
  • Tumour
  • Ectopic surgery, past abdominal surgery
  • Sterilization
  • Fibroids and endometriosis
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14
Q

What kind of questions would we want to ask a woman when assessing fertility? [8]

A
  • Duration of infertility
  • Past Fertility
  • Past pregnancies and complications of each
  • Past Contraception
  • PMH
  • Menstrual History
  • Sexual History
  • Psychological Assessment
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15
Q

What would you assess on exam when thinking of infertility? [5]

A 
Weight, height --> BMI
Fat and Hair Distribution (ddx hirsutism of androgen excesss)
Galactorrhoea (prolactinoma)
Abdo Exam
Pelvic Exam for masses or fibroids
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16
Q

What baseline tests can be done in primary care to assess fertility - for both male and female partners [5]

A
  • Rubella immunity
  • Chlamydia
  • TSH
  • Ovulatory function
  • Male: semen analysis
17
Q

Baseline investigations outside a specialist fertility clinic to assess fertility?
How do we test for ovulation? [3]

A

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

18
Q

Once at a fertility clinic we can do futher tests for women, what do these include? [4]

A

Physical exam
Lab work - ovulatory fxn
Transvaginal US looking for masses, structural abnormalities
Tubal Patency test looking for Tubal Block

19
Q

2 options - investigation of tubal block

A

Either with a HyCoSo (Hysterosalpingo-contrast-sonography)

Or Laparoscopy

20
Q

How does IVF work? [4]

A

Harvest eggs from ovary
Fertilise with sperm in lab
~5days incubation
Implant embryo using transfer catheter

21
Q

ICSI is another form of IVF, how does it work? [1]

A

Injection of a single sperm into mature eggs instead of mixing the two in a lab and allowing for normal fertilisation

22
Q

What are the referral (to specialist) guidelines - with age as risk factor [3]

A

<35 yo - refer after 1 year
35-45 - refer after 6m
>45 yo - little can be offered

23
Q

Definitions: Infertility [2]

A

Defined as inability of a couple to conceive after 12 months of regular intercourse without use of contraception.

24
Q

Definitions: Primary infertility

A

Primary infertility: refers to couples who have not become pregnant after at least 1 year having sex without using birth control methods.

25
Q

Definitions: Secondary infertility [1]

A

Secondary infertilityrefers to couples who have been able to get pregnant at least once, but now are unable

26
Q

Group 1 ovulatory disorders:

Causes [4]

A

Low body weight, stress, exercise-related amenorrhea
Craniopharyngioma or other tumours affecting hypothalamus
Amenorrhea combined with anosmia – Kallmann’s syndrome
Idiopathic

27
Q

Group 2 ovulatory disorders:

What are 3 disorders under this category?

A

Androgen excess
Infrequent periods
Polycystic ovaries (PCOS)

28
Q

2 differentials for hirsutism secondary to androgen excess

A

Androgen secreting tumours

Ovarian hyperthecosis

29
Q

Ix for androgen excess disorders
1 clinical
3 biochemical
1 imaging

A

Clinical dx - Ferriman Gallwey score
Biochemical measurement of testosterone, DHEAS, 17-OH progesterone
Adrenal CT

30
Q

Rotterdam Criteria - specific details of:
Oligo/anovulation [2]

Ultrasound findings [2]

A

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

31
Q

Symptoms of virilisation [7]

seen in PCOS

A 
Excess facial and body hair or baldness
Acne
Deepening of voice
Increased muscularity, sex drive
Uterine and breast atrophy
Clitoral enlargement
Amenorrhea
32
Q

Methods to measure testosterone [3]

A

Free testosterone
Free androgen index
Bioavailable testosterone

33
Q

Management of infertility
Anovulation [3]
Tubal disease [2]
Intrauterine adhesions

A 
Anovulation: 
- weight loss/gain, clomifene, gonadotrophins, laparoscopic ovarian drilling
Tubal disease: 
- tubal catheterization
- hysteroscopic cannulation
Intrauterine adhesions:
- hysteroscopic adenolysis
34
Q

IVF indications

A 
Tubal disease
Male factor subfertility,
Endometriosis
Anovulation not responding to clomiphene
Maternal age
Unexplained subfertility >2yrs

Repro (34 decks)

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