Management of infertility Flashcards
What is infertility?
Failure to achieve a clinical pregnancy despite 12 months of regular unprotected sex in couple who have never had a child before.
Why does weight cause issues?
Increases rate of miscarriage by 2/3x
Increased erectile dysfunction
Decreases success rate with fertility treatment.
Decreases fertility and sperm motility
What vaccine is given prior to attempts at conception?
MMR vaccine, must have been on contraception for 4 weeks prior.
Why is the MMR vaccine given?
As rubella causes serious issues in the foetus.
What does rubella increase the risk of in pregnancy?
Microcephaly
Patent ductus arteriousus
Cataracts
Rash
What types of ovulary disorders are there?
Type I
Type II
Type III
Other
What is a type I ovulatory disorder?
Hypothalamic
How does a type I hypothalamic disorder present?
Low FSH LH Oestrogen
Normal Prolactin
-ve Progesteron challenge
Amenorrhea
What is a type II ovulatory disorder?
Hypothalamic Pituitary dysfunction
What is a type III ovulatory disorder?
Ovarian failure
What is the mainstay of treatment in a type III ovulatory disorder?
Combined contraceptive pill
HRT
Egg preservation
Counselling
What are the other causes of infertility?
Hyperprolactinaemia
Hypothyroidism
What is the main type I ovulatory disorder?
Hypogonadotrophic hypogonadism
Failure to release adequate GnRH from hypothalamus
What are some causes of type I ovulatory disorders ?
Stress Excessive exercise Anorexia Pituitary tumour Head trauma Steroid and opiates
What must be done before treatment of a type I ovulatory disorder?
Stabilise weight Reduce alcohol and smoking Folic acid Rubella vaccine Semen analysis
What two options are there for the treatment of a type 1 ovulatory disorder?
Pulsatile GnRH
Gonadotrophin injections
What is the GnRH pump?
Induces ovulation by inducing the correct levels of LH and FSH.
Are there any risks associated with the pulsatile GnRH pump?
Low multiple pregnancy risk
What are the gonadotrophin injections?
LH and FSH administered daily
Are there any risks associated with the gonadotrophin injections?
High multiple pregnancy risk
What do both the gonadotropin injections and the pulsatile GnRH pump require?
USS monitoring of the follicles.
What is the most common type II ovulatory disorder?
Polycystic ovarian syndrome
PCOS
How does PCOS present biochemically?
Normal gonadotrophins / excess LH
Normal oestrogen
Increased free testosterone
How does PCOS present clinically?
Oligo/Amenorrhea
Insulin resistance
What is the mainstay of treatment for PCOS?
Clomifene
+ metformin for insulin resistance and improved sensitivity
+Gonadotrophin injections
What are the risks associated with PCOS treatment?
Multiple pregnancy risk
What are the three hallmarks associated with PCOS?
Hyperandrogenism
Hirsutism
Cystic ovaries on USS- Pearl necklace
What are some of the risks associated with multiple pregnancy to the mother?
Hyperemesis Anaemia Pre eclampsia Gestational diabetes Post partum haemorrhage Post natal depression
What are some of the risks associated with multiple pregnancy to the foetus’s?
Low birth weight
Increased miscarriage
Increased risk of disability
Increased risk of perinatal death
What is pre eclampsia?
The onset of hypertension during pregnancy resulting in seizures low platelet counts and oedema.
What is twin twin transfusion syndrome?
Unbalanced vascular communication resulting in one receiving more blood and nutrients than the other.
Significant cause of perinatal mortality. 80-100% fatality
What is the treatment for twin twin transfusion syndrome?
Laser division of the vessels
What are the risks associated with prematurity?
Increased risk of respiratory distress syndrome
Reduced IQ
Increased risk of ADHD speech issues etc
What is premature ovarian failure?
Halt of periods before 40
What are some causes of premature ovarian failure?
Turners
Idiopathic
Chemotherapy
Radiotherapy
What are some clinical signs of premature ovarian failure?
Flushes
Night sweats
Atrophic vaginitis
Hoe does premature ovarian failure present biochemically?
High FSH and LH
Low oestrogen
What are some infective causes of tubal diseases?
Pelvis inflammatory - STI TB
Trans peritoneal appendicitis
What are some non infective causes of tubal damage?
Endometriosis Surgical Fibrosis Fibroids Polyps
What are some signs of a pelvis infection?
Abdominal pain Vaginal discharge Menorrhagea Infertility Ectopic pregnancy
What is endometriosis?
Endometrial glands located outside the uterine cavity
How does endometriosis present?
Dysmenorrhea Painful defecation Chronic pelvic pain Chocolate cysts on ovary Infertility
What are the types of fibroids?
Pedunculated
Subserous
Submucous
Intramural
Of the different types of fibroids which ones are generally operated on?
Submucos and intramural
What surgical treatment can be used for PCOS
Laparascopic Ovarian Diathermy
Literally drilling holes in the ovaries
What are the risks associated with laparoscopic ovarian diathermy?
Risk of ovarian destruction or adhesions
What are the types of male infertility?
Post Testicular
Testicular
Pre Testicular
Non ob
Name some causes of post testicular infertility?
CF
Vasectomy
Duct Obstruction
Accessory gland infection
How does post testicular infertility present biochemically?
Testosterone FSH and LH levels are all normal
What is the management of someone with post testicular infertility usually?
USS guided surgical removal of sperm
Name some causes of testicular infertility?
Klinefelters immotile cilia syndrome Heat Irradiation Drugs Chemotherapy Testicular torsion
How does testicular infertility clinically present?
Low sperm count
What is the main cause of pre testicular infertility?
Hypogonadism
How does pre testicular infertility present both clinically and biochemically?
Low FSH LH and Testosterone
Erectile dysfunction
What are some common causes of a non obstructive infertility?
Chemotherapy
Radiation
Klinefelters
How does non obstructive infertility present biochemically ?
FSH and LH is high
Testosterone is Low
How does non obstructive infertility present clinically?
Low testicular volume
Reduced secondary sexual characteristics
Vas deferens is present
List some factors that increase infertility
Precocious pregnancy Smoking >2 cups of coffee Recreational drugs BMI over 30 Over 30
What is anovulatory infertility?
Where the ovaries don’t release an oocyte during the menstrual cycle.
What are the physiological causes of anovulatory infertility?
Pre puberty
Pregnancy
Lactation
Menopause
What are some gynaecological causes of anovulatory infertility?
Hypothalamic- anorexia bulimia excessive exercise
Endocrine- Hyperprolactinaemia tumours Sheehan
Ovarian- PCOS premature ovarian failure
List some other causes of anovulatory infertility?
Systematic- chronic renal failure
Endocrine- testosterone secreting tumours
What is Sheehans syndrome?
Hypoxic damage to the pituitary during childbirth caused by severe haemorrhage, leading to the failure of the pituitary gland.