O&G: Fertility Flashcards
Infertility
when should inx and referral for infertility be initiated
after the couple has been trying to conceive without success for 12 months
6 months if the woman is older than 35
Infertility
causes
- sperm problems (30%)
- ovulation problems (25%)
- unexplained (20%)
- tubal problems (15%)
- uterine problems (10%)
Infertility
general lifestyle advice
- woman: take 400mcg folic acid daily
- healthy BMI
- avoid smoking + alcohol
- reduce stress
- intercourse every2-3d
- avoid timing intercourse
Infertility
why is timed intercourse to coincide with ovulation not necessary
it can lead to increased stress and pressure in relationship
Infertility
initial inx, in primary care
- BMI
- chlamydia screening
- semen analysis
- female hormonal testing
- rubella immunity in the mother
Infertility
what could a low BMI indicate
anovulation
Infertility
what could a high BMI indicate
PCOS
Infertility
what female hormone testing is involved
- serum LH + FSH on day 2-5 of the cycle
- serum progesterone day 21
- anti-mullerian hormone
- TFTs
- prolactin if sx of galactorrhea or amenorrhoea
Infertility
what does high FSH suggest
poor ovarian reserve (number of follicles that the woman has left in her ovaries)
pituitary gland is producing extra FSH in an attempt to stimulate follicular development
Infertility
what does high LH suggest
PCOS
Infertility
what does a rise in progesterone on day 21 indicate
ovulation has occurred , and the corpus luteum has formed and started secreting progesterone
Infertility
what is the most accurate marker of ovarian reserve
anti-mullerian hormone
It is released by the granulosa cells in the follicles and falls as the eggs are depleted
Infertility
what does a high level of anti-mullerian hormone indicate
a good ovarian reserve
Infertility
what further inx are performed in secondary care
- pelvis US: PCO or abnormalities in uterus
- hysterosalpingogram: patency of fallopian tubes
- laparoscopy + dye test: patency of fallopian tubes, adhesions + endometriosis
Infertility
mnx options when anovulation is the cause
- weight loss
- clomifene
- letrozole (aromatase inhibitor with anti-oestrogen effects)
- gonadotropins
- ovarian drilling in PCOS
- metformin
Infertility
what is used when women are resistant to clomifene
gonadotropins
Infertility
how does clomifene work
anti-oestrogen (a selective oestrogen receptor modulator)
given on day 2-6. Stops the -ve feedback of oestrogen on the hypothalamus
more GnRH and thus FSH + LH
Infertility
mnx for women with alterations to the fallopian tubes
- Tubal cannulation during a hysterosalpingogram
- Laparoscopy to remove adhesions or endometriosis
- IVF
Infertility
mnx of uterine factors
Surgery may be used to correct polyps, adhesions or structural abnormalities affecting fertility
Infertility
mnx for when there is a blockage somewhere along the vas deferens preventing sperm from reaching the ejaculated semen
Surgical sperm retrieval: a needle and syringe is used to collect sperm directly from the epididymis through the scrotum.
surgical correction
Infertility
mnx of sperm problems
- Surgical sperm retrieval
- Surgical correction
- Intra-uterine insemination
- Intracytoplasmic sperm injection (ICSI)
- Donor insemination
Infertility
what is intra-uterine insemination
collecting and separating out high-quality sperm, then injecting them directly into the uterus to give them the best chance of success
Infertility
what is intracytoplasmic sperm injection (ICSI)
injecting sperm directly into the cytoplasm of an egg
These fertilised eggs become embryos, and are injected into the uterus of the woman
Infertility
what is donor insemination
sperm from a donor is another option for male factor infertility.
Male Factor Infertility
what does semen analysis examine
the quantity and quality of semen and sperm. It assesses for male factor infertility.
Male Factor Infertility
what clear instructions should be given when asking men to provide a sample
- Abstain from ejaculation for at least 3d and at most 7d
- Avoid hot baths, sauna and tight underwear during the lead up to providing a sample
- Attempt to catch the full sample
- Deliver the sample to the lab within 1h of ejaculation
- Keep the sample warm (e.g. in underwear) before delivery
Male Factor Infertility
factors affecting semen analysis and sperm quality and quantity
- Hot baths
- Tight underwear
- Smoking
- Alcohol
- Raised BMI
- Caffeine
Male Factor Infertility
when is a repeat sample indicated
after 3 months in borderline results
2-4w with very abnormal results
Male Factor Infertility
what is a normal semen volume
> 1.5ml
Male Factor Infertility
what is a normal semen pH
> 7.2
Male Factor Infertility
what is a normal concentration of sperm
> 15 million per ml
Male Factor Infertility
what is a normal total number of sperm
> 39 million per sample
Male Factor Infertility
how much sperm is normally mobile
> 40%
Male Factor Infertility
how much sperm is normally active (vitality)
> 58%
Male Factor Infertility
what is the normal percentage of normal sperm
> 4%
Male Factor Infertility
definition of Polyspermia (or polyzoospermia)
high number of sperm in the semen sample (>250 million per ml).
Male Factor Infertility
what is oligospermia (or oligozoospermia)
a reduced number of sperm in the semen sample
Male Factor Infertility
definition of mild oligospermia
10 to 15 million / ml
Male Factor Infertility
definition of moderate oligospermia
5 to 10 million / ml
Male Factor Infertility
definition of severe oligospermia
<5 million / ml
Male Factor Infertility
definition of Cryptozoospermia
very few sperm in the semen sample (less than 1 million / ml).
Male Factor Infertility
definition of Azoospermia
absence of sperm in the semen.
Male Factor Infertility
what is necessary for sperm creation
testosterone
Male Factor Infertility
pre-testicular causes
Hypogonadotrophic hypogonadism (low LH and FSH resulting in low testosterone):
- Pathology of the pituitary gland or hypothalamus
- Suppression due to stress, chronic conditions or hyperprolactinaemia
- Kallman syndrome
Male Factor Infertility
testicular causes (testicular damage)
- Mumps
- Undescended testes
- Trauma
- Radiotherapy
- Chemotherapy
- Cancer
Male Factor Infertility
testicular causes (Genetic or congenital disorders that result in defective or absent sperm production)
- Klinefelter syndrome
- Y chromosome deletions
- Sertoli cell-only syndrome
- Anorchia (absent testes)
Male Factor Infertility
Post-testicular causes
Obstruction preventing sperm being ejaculated:
- Damage to the testicle or vas deferens from trauma, surgery or cancer
- Ejaculatory duct obstruction
- Retrograde ejaculation
- Scarring from epididymitis, for example, caused by chlamydia
- Absence of the vas deferens (may be associated with cystic fibrosis)
- Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)
Male Factor Infertility
initial inx for investigating abnormal semen analysis
history, exam, repeat sample + US of testes
Male Factor Infertility
further inx by urologist
- Hormonal analysis with LH, FSH and testosterone levels
- Genetic testing
- Further imaging: transrectal US or MRI
- Vasography: injecting contrast into the vas deferens and performing xray to assess for obstruction
- Testicular biopsy
Male Factor Infertility
management
- Surgical sperm retrieval where there is obstruction
- Surgical correction of an obstruction in the vas deferens
- Intra-uterine insemination injection (ICSI)
- Donor insemination
In Vitro Fertilisation
what does it involve
fertilising an egg with sperm in a lab, then injecting the resulting embryo into the uterus
In Vitro Fertilisation
what is intrauterine insemination (IUI)
injecting sperm into the uterus, avoiding intercourse
In Vitro Fertilisation
when is IUI used
- donor sperm for same-sex couples
- HIV (avoiding unprotected sex)
- practical issues with vaginal sex.
In Vitro Fertilisation
what does a cycle of IVF involve
a single episode of ovarian stimulation and collection of oocytes (eggs)
which may produce several embryos
In Vitro Fertilisation
process
- Suppressing the natural menstrual cycle
- Ovarian stimulation
- Oocyte collection
- Insemination / intracytoplasmic sperm injection (ICSI)
- Embryo culture
- Embryo transfer
In Vitro Fertilisation
what are the 2 protocols for the suppression of the natural menstrual cycle
- GnRH agonist protocol
- GnRH antagonist protocol
In Vitro Fertilisation
why do you need to suppress the natural menstrual cycle
ovulation would occur and the follicles that are developing would be released before it is possible to collect them
In Vitro Fertilisation
what is involved in ovarian stimulation
- SC FSH on day 2, over 10-14d
- which stimulates follicles
- hCG injection given 36h before collection of eggs which stimulates final maturation of follicles
In Vitro Fertilisation
what is involved in oocyte collection
- oocytes collected from ovaries under guidance of TVUS
- needle inserted to aspirate fluid from each follicle (which contains the mature oocytes)
- under sedation (not GA)
In Vitro Fertilisation
what is involved in oocyte insemination
- sperm + egg are mixed in culture medium
- thousands of sperm need to be combine with each oocyte to produce enough enzymes (e.g. hyaluronic acid)
- for 1 sperm to penetrate the corona radiata and zona pellucida and fertilise the egg
In Vitro Fertilisation
when is Intracytoplasmic sperm injection (ICSI used
mainly for male factor infertility, where there are a reduced number or quality of sperm
In Vitro Fertilisation
what happens in intracytoplasmic sperm injection (ICSI)
- semen sample is produced,
- the highest quality sperm are isolated
- and injected directly into the cytoplasm of the egg.
In Vitro Fertilisation
what happens in embryo culture
- left in an incubator and observed over 2 – 5 days
- monitored until they reach the blastocyst stage
In Vitro Fertilisation
what happens in embryo transfer
- highest quality embryos are selected for transfer
- catheter inserted under US guidance thru cervix into uterus
- 1 embryo transferred
In Vitro Fertilisation
when is a pregnancy test performed
around day 16 after egg collection
In Vitro Fertilisation
why is progesterone vaginal suppositories given from the time of oocyte collection until 8 – 10 weeks gestation
to mimic the progesterone that would be released by the corpus luteum during a typical pregnancy
In Vitro Fertilisation
complications relating to the overall process
- failure
- multiple pregnancy
- ectopic pregnancy
- ovarian hyperstimulation syndrome
In Vitro Fertilisation
complications relating to the egg collection procedure
- pain
- bleeding
- pelvic infection
- damage to the bladder or bowel
Ovarian Hyperstimulation Syndrome
what is it
a complication of ovarian stimulation during IVF
associated w/ use of hCG to mature the follicles during the final steps of ovarian stimulation
Ovarian Hyperstimulation Syndrome
pathophysiology
- LH + FSH during ovarian stimulation result in development of multiple follicles
- “trigger injection” of hCG
- granulosa cells of the follicles release VEGF
- causing fluid to leak from capillaries
- fluid moves from intravascular to extravascular space
- resulting in oedema, ascites + hypovolaemia
Ovarian Hyperstimulation Syndrome
why is there raised renin level
activation of the RAAS
renin level correlates with the severity of the condition
Ovarian Hyperstimulation Syndrome
RFs
- Younger age
- Lower BMI
- Raised anti-Müllerian hormone
- Higher antral follicle count
- PCOS
- Raised oestrogen levels during ovarian stimulation
Ovarian Hyperstimulation Syndrome
prevention
During stimulation with gonadotrophins, they are monitored with:
- Serum oestrogen levels (higher levels indicate a higher risk)
- US monitor of the follicles (higher number and larger size indicate a higher risk)
Ovarian Hyperstimulation Syndrome
what strategies are used in high risk women to reduce the risk
- GnRH antagonist protocol (rather than the GnRH agonist protocol)
- Lower doses of gonadotrophins
- Lower dose of the hCG injection
- Alternatives to the hCG injection (i.e. a GnRH agonist or LH)
Ovarian Hyperstimulation Syndrome
early OHSS presents within how many days of the hCG injection
7d
Ovarian Hyperstimulation Syndrome
late OHSS presents within how many days of the hCG injection
10d
Ovarian Hyperstimulation Syndrome
features
- Abdo pain + bloating
- N + V
- Diarrhoea
- Hypotension
- Hypovolaemia
- Ascites
- Pleural effusions
- Renal failure
- Peritonitis from rupturing follicles releasing blood
- Prothrombotic state (risk of DVT and PE)
Ovarian Hyperstimulation Syndrome
severity: mild
abdo pain + bloating
Ovarian Hyperstimulation Syndrome
severity: moderate
N+V w/ ascites seen on US
Ovarian Hyperstimulation Syndrome
severity: severe
- ascites
- low urine output
- low serum albumin
- high potassium
- raised haematocrit (>45%)
Ovarian Hyperstimulation Syndrome
severity: critical
- tense ascites
- no urine output
- thromboembolism
- acute resp distress syndrome
Ovarian Hyperstimulation Syndrome
mnx
supportive:
- oral fluids
- monitoring of urine output
- LMWH
- paracentesis of ascites if required
- IV colloids (e.g. human albumin solution)
Ovarian Hyperstimulation Syndrome
which patients may require admission
severe –> admit
critical –> ITU
Ovarian Hyperstimulation Syndrome
what is haematocrit
the concentration of red blood cells in the blood
Ovarian Hyperstimulation Syndrome
why is haematocrit monitored
to assess the volume of fluid in the intravascular space
When the haematocrit goes up, this indicates less fluid in the intravascular space, as the blood is becoming more concentrated
Ovarian Hyperstimulation Syndrome
what can raised haematocrit indicate
dehydration
