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Endocrinology > Management of Infertility > Flashcards

Management of Infertility Flashcards

1
Q

What is infertility?

A

Failure to conceive despite regular unprotected sex over 12 months in absence of known reproductive pathology

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2
Q

Primary vs. secondary infertility?

A

Primary: couple never conceived
Secondary: couple previously conceived

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3
Q

Which infection associated with infertility?

A

Chlamydia

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4
Q

Test for chlamydia?

A

Endocervical swab

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5
Q

How do you check for rubella immunity?

A

Bloods

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6
Q

When do you check progesterone level when investigating infertility?

A

MIDLUTEAL PHASE
(day 21 of 28 day cycle, or 7 days prior to expected period in prolonged cycle)
MUST TAKE 2 SAMPLES

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7
Q

Progesterone over which level (nmol/l) is suggestive of ovulation?

A

> 30nmol/l

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8
Q 
Rash at birth
Low birth weight
Small head size
Heart abnormalities
Visual problems
Bulging fontanelles
A

Rubella syndrome

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9
Q

Microcephaly
Cataracts
Patent ductus arteriosus

A

Rubella syndrome

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10
Q

Short term complications of pelvic inflammatory disease (e.g. chalmydia)

A

Tubo-ovarian abscess
Peritonitis
Fitz-High-Curtis syndrome

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11
Q

Long term consequences of pelvic inflammatory disease?

A

Chronic pelvic pain
Infertility
Ectopic pregnancy

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12
Q

Fitz-Hugh-Curtis Syndrome?

A

upper quadrant pain (inflammation of liver capsule or diaphragm from spread of infection from pelvic inflammatory disease)

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13
Q

What is a hydrosalpinx?

A

Distally blocked fallopian tube filled with serous/clear fluid

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14
Q

Group I ovulatory disorders?

A

Hypothalamic

amenorrhea-includes stress, excessive exercise, anorexia, Kallman’s syndrome, isolated gonadotropin deficiency

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15
Q

Findings of group I ovulatory disorders

A

Low FSH, estrogen, normal prolactin, negative progesterone challenge

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16
Q

Group II hypothalamic pituitary dysfunction

A

Normogonadotrophic-normoestrogenic anovulation

e.g. PCOS

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17
Q

Group III ovulatory disorders

A

Ovarian failure

-high gonadotrophins with low estrogens

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18
Q

Which type of ovulatory disorder is PCOS?

A

Type II (hypothalamic-pituitary dysfunction)

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19
Q

Hysterosalpingogram

A

x-ray that examines the uterus and the fallopian tubes and the surrounding area

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20
Q

Commonest cause of anovulatory infertility?

A

Polycystic ovary syndrome

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21
Q

Increased ovarian volume?

A

> 10ml

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22
Q

How many follicles in PCOS?

A

More than 12 (between 2-8mm)

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23
Q

Diagnosis of PCOS (Rotterdam criteria)

A 
-Irregular menstrual cycle, hirsutism, acne, subfertility, alopecia, obesity, acanthosis nigricans
Biochemical: day 2 - day 5
-elevated serum LH (>10IU/L)
-LH/FSH ratio >2
-normal estradiol
-low progesterone
-normal or mildly elevated prolactin
-raised testosterone/FAI/A4
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24
Q

LH/FSH ratio in PCOS?

A

LH/FSH ratio >2

25
Q

Serum LH in PCOS?

A

Elevated serum LH (>10IU/L)

26
Q

Estradiol in PCOS?

27
Q

Progesterone in PCOS?

28
Q

Testosterone in PCOS?

29
Q

Clomifene citrate

Tamoxifen

A

Antioestrogens

30
Q

Letrozole

A

Aromatase inhibitors

31
Q

Ovulation induction: first line of treatment

A

Antioestrogens: clomifene citrate
Tamoxifen
Aromatase inhibitors: letrozole

32
Q

How do you clomifene citrate (anti-oestrogens)

A

Monitor with tracking scan and serum progesterone

33
Q

When do you give clomifene citrate?

A

Day 2- day 6 for 5 days

34
Q

When do you give tamoxifen?

A

Day 2-6 for five days

35
Q

Adverse effect of tamoxifen?

A

Estrogenic effect on endometrium

36
Q

First line treatment for PCOS?

A

Anti-oestrogens: Clomifene citrate/tamoxifen

Aromatase inhibitors: Letrozole

37
Q

Second line treatment for PCOS?

A

1) clomifene citrate + metformin
2) Gonadotropin therapy: daily injections (FHS and LH etc)
3) Laparoscopic ovarian diathermy

38
Q

Investigating semen in men?

A

Semen analysis: twice over six weeks apart

  • If abnormal, do an endocrine profile
  • if SEVERELY abnormal –> do endocrine profile AND chromosome analysis and screen for cystic fibrosis, testicular biopsy
39
Q

Most common cause of male infertility?

A

Idiopathic

40
Q

Vasectomy, infection (e.g. chlamydia/gonorrhoea), congenital absence of vas deferens (e,.g. cystic fibrosis)

A

Obstructive causes of male infertility

41
Q

Undescended testis, orchitis (e.g. mumps), torion/trauma, chromosomal (e.g. Klinefelter’s syndrome) Kartagener syndrome, Y chromsome micro deletions

A

Non-obstructive causes

42
Q

Hormonal causes of infertility?

A

Hypogonadotrophic hypogonadism
Hypothyroidism
Hyperprolactinemia

43
Q

PESA

A

percutaneous epididymal sperm aspiration
-you can also do percutaneous testicular sperm aspiration

(both you put a needle in to take out the sperm)

44
Q

MESA

A

Microsurgical epididymal sperm aspiration

45
Q

When do you do hysterosalpingogram/laparoscopy & dye?

A

In the first 10 days of cycle

-be careful in obesoty, previous pelvic surgery and Crohn’s disease

46
Q

Salpingitis isthmica nodosa?

A

Diverticulosis of the fallopian tube = nodular thickening of the narrow part of the uterine tube due to inflammation

47
Q

Fibroids

A

Non-cancerous growths in the uterus

48
Q

Treatment of tubal disease

A

Tubal surgery
Selective salpingiogrpahy and catheterisation
In-vitro fertilisation

49
Q

How many times should you have sex?

A

2-3 times a week

50
Q

How much alcohol should women drink?

A

Limit to 4 units per week

51
Q

Optimal weight for fertility?

52
Q

Folic acid for fertility?

A

0.4mg/day preconception till 12 weeks gestation

53
Q

When would you do hysteroscopy?

A

Only performed in cases where suspected or known endometrial pathology: i.e. uterine septum, adhesions, polyp

54
Q

When would you do pelvic ultrasound?

A

perform when abnormality on pelvic examination: e.g. enlarged uterus/adnexal mass
when required from other investigations: e.g. possible polyp seen at HSG

55
Q

What is endometriosis?

A

Presence of endometrial glands outside the uterine cavity

56
Q

Symptoms of endometriosis

A

dysmenorrhoea, dysparenuia, menorrhagia, painful defaecation, chronic pelvic pain (severity of pain may be disproportionate to extent of disease)

57
Q

Why does endometriosis affect fertility?

A

Reasons impaired infertility: anatomical damage (tubo-ovarian adhesions), dyspareunia, altered peritoneum environment (cytotoxic factors: impaired ovulation, lower embryo quality and impaired implantation)

58
Q

Treatment for endometriosis?

A

Medical: combined oral contraceptive pill, progesterones (medroxyprogesterone acetate), GnRH agonists (zoladex +/- add back HRT)
Surgical : Laparoscopic ablation/resection and adhesiolysis of mild disease
Radical resection of severe endometriosis
Drainage and ablation cyst base for endometriomas (consider prior to IVF)
In-Vitro Fertilisation

59
Q

Treatment of premature menopause

A 
Counselling
Fertility: oocyte donation
Prevention osteoporosis (OCP, HRT
Cryopreservation of ovarian tissue (prior to radiotherapy or chemotherapy)

Endocrinology (30 decks)

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