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Finals > O&G: Fertility > Flashcards

O&G: Fertility Flashcards

1
Q

Infertility

when should inx and referral for infertility be initiated

A

after the couple has been trying to conceive without success for 12 months

6 months if the woman is older than 35

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2
Q

Infertility

causes

A
  • sperm problems (30%)
  • ovulation problems (25%)
  • unexplained (20%)
  • tubal problems (15%)
  • uterine problems (10%)
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3
Q

Infertility

general lifestyle advice

A
  • woman: take 400mcg folic acid daily
  • healthy BMI
  • avoid smoking + alcohol
  • reduce stress
  • intercourse every2-3d
  • avoid timing intercourse
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4
Q

Infertility

why is timed intercourse to coincide with ovulation not necessary

A

it can lead to increased stress and pressure in relationship

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5
Q

Infertility

initial inx, in primary care

A
  • BMI
  • chlamydia screening
  • semen analysis
  • female hormonal testing
  • rubella immunity in the mother
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6
Q

Infertility

what could a low BMI indicate

A

anovulation

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7
Q

Infertility

what could a high BMI indicate

A

PCOS

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8
Q

Infertility

what female hormone testing is involved

A
  • 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
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9
Q

Infertility

what does high FSH suggest

A

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

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10
Q

Infertility

what does high LH suggest

A

PCOS

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11
Q

Infertility

what does a rise in progesterone on day 21 indicate

A

ovulation has occurred , and the corpus luteum has formed and started secreting progesterone

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12
Q

Infertility

what is the most accurate marker of ovarian reserve

A

anti-mullerian hormone

It is released by the granulosa cells in the follicles and falls as the eggs are depleted

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13
Q

Infertility

what does a high level of anti-mullerian hormone indicate

A

a good ovarian reserve

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14
Q

Infertility

what further inx are performed in secondary care

A
  • pelvis US: PCO or abnormalities in uterus
  • hysterosalpingogram: patency of fallopian tubes
  • laparoscopy + dye test: patency of fallopian tubes, adhesions + endometriosis
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15
Q

Infertility

mnx options when anovulation is the cause

A
  • weight loss
  • clomifene
  • letrozole (aromatase inhibitor with anti-oestrogen effects)
  • gonadotropins
  • ovarian drilling in PCOS
  • metformin
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16
Q

Infertility

what is used when women are resistant to clomifene

A

gonadotropins

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17
Q

Infertility

how does clomifene work

A

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

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18
Q

Infertility

mnx for women with alterations to the fallopian tubes

A
  • Tubal cannulation during a hysterosalpingogram
  • Laparoscopy to remove adhesions or endometriosis
  • IVF
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19
Q

Infertility

mnx of uterine factors

A

Surgery may be used to correct polyps, adhesions or structural abnormalities affecting fertility

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20
Q

Infertility

mnx for when there is a blockage somewhere along the vas deferens preventing sperm from reaching the ejaculated semen

A

Surgical sperm retrieval: a needle and syringe is used to collect sperm directly from the epididymis through the scrotum.

surgical correction

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21
Q

Infertility

mnx of sperm problems

A
  • Surgical sperm retrieval
  • Surgical correction
  • Intra-uterine insemination
  • Intracytoplasmic sperm injection (ICSI)
  • Donor insemination
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22
Q

Infertility

what is intra-uterine insemination

A

collecting and separating out high-quality sperm, then injecting them directly into the uterus to give them the best chance of success

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23
Q

Infertility

what is intracytoplasmic sperm injection (ICSI)

A

injecting sperm directly into the cytoplasm of an egg

These fertilised eggs become embryos, and are injected into the uterus of the woman

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24
Q

Infertility

what is donor insemination

A

sperm from a donor is another option for male factor infertility.

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25
Q

Male Factor Infertility

what does semen analysis examine

A

the quantity and quality of semen and sperm. It assesses for male factor infertility.

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26
Q

Male Factor Infertility

what clear instructions should be given when asking men to provide a sample

A
  • 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
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27
Q

Male Factor Infertility

factors affecting semen analysis and sperm quality and quantity

A
  • Hot baths
  • Tight underwear
  • Smoking
  • Alcohol
  • Raised BMI
  • Caffeine
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28
Q

Male Factor Infertility

when is a repeat sample indicated

A

after 3 months in borderline results

2-4w with very abnormal results

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29
Q

Male Factor Infertility

what is a normal semen volume

A

> 1.5ml

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30
Q

Male Factor Infertility

what is a normal semen pH

A

> 7.2

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31
Q

Male Factor Infertility

what is a normal concentration of sperm

A

> 15 million per ml

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32
Q

Male Factor Infertility

what is a normal total number of sperm

A

> 39 million per sample

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33
Q

Male Factor Infertility

how much sperm is normally mobile

A

> 40%

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34
Q

Male Factor Infertility

how much sperm is normally active (vitality)

A

> 58%

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35
Q

Male Factor Infertility

what is the normal percentage of normal sperm

36
Q

Male Factor Infertility

definition of Polyspermia (or polyzoospermia)

A

high number of sperm in the semen sample (>250 million per ml).

37
Q

Male Factor Infertility

what is oligospermia (or oligozoospermia)

A

a reduced number of sperm in the semen sample

38
Q

Male Factor Infertility

definition of mild oligospermia

A

10 to 15 million / ml

39
Q

Male Factor Infertility

definition of moderate oligospermia

A

5 to 10 million / ml

40
Q

Male Factor Infertility

definition of severe oligospermia

A

<5 million / ml

41
Q

Male Factor Infertility

definition of Cryptozoospermia

A

very few sperm in the semen sample (less than 1 million / ml).

42
Q

Male Factor Infertility

definition of Azoospermia

A

absence of sperm in the semen.

43
Q

Male Factor Infertility

what is necessary for sperm creation

A

testosterone

44
Q

Male Factor Infertility

pre-testicular causes

A

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
45
Q

Male Factor Infertility

testicular causes (testicular damage)

A
  • Mumps
  • Undescended testes
  • Trauma
  • Radiotherapy
  • Chemotherapy
  • Cancer
46
Q

Male Factor Infertility

testicular causes (Genetic or congenital disorders that result in defective or absent sperm production)

A
  • Klinefelter syndrome
  • Y chromosome deletions
  • Sertoli cell-only syndrome
  • Anorchia (absent testes)
47
Q

Male Factor Infertility

Post-testicular causes

A

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)
48
Q

Male Factor Infertility

initial inx for investigating abnormal semen analysis

A

history, exam, repeat sample + US of testes

49
Q

Male Factor Infertility

further inx by urologist

A
  • 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
50
Q

Male Factor Infertility

management

A
  • Surgical sperm retrieval where there is obstruction
  • Surgical correction of an obstruction in the vas deferens
  • Intra-uterine insemination injection (ICSI)
  • Donor insemination
51
Q

In Vitro Fertilisation

what does it involve

A

fertilising an egg with sperm in a lab, then injecting the resulting embryo into the uterus

52
Q

In Vitro Fertilisation

what is intrauterine insemination (IUI)

A

injecting sperm into the uterus, avoiding intercourse

53
Q

In Vitro Fertilisation

when is IUI used

A
  • donor sperm for same-sex couples
  • HIV (avoiding unprotected sex)
  • practical issues with vaginal sex.
54
Q

In Vitro Fertilisation

what does a cycle of IVF involve

A

a single episode of ovarian stimulation and collection of oocytes (eggs)

which may produce several embryos

55
Q

In Vitro Fertilisation

process

A
  • Suppressing the natural menstrual cycle
  • Ovarian stimulation
  • Oocyte collection
  • Insemination / intracytoplasmic sperm injection (ICSI)
  • Embryo culture
  • Embryo transfer
56
Q

In Vitro Fertilisation

what are the 2 protocols for the suppression of the natural menstrual cycle

A
  • GnRH agonist protocol

- GnRH antagonist protocol

57
Q

In Vitro Fertilisation

why do you need to suppress the natural menstrual cycle

A

ovulation would occur and the follicles that are developing would be released before it is possible to collect them

58
Q

In Vitro Fertilisation

what is involved in ovarian stimulation

A
  • 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
59
Q

In Vitro Fertilisation

what is involved in oocyte collection

A
  • 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)
60
Q

In Vitro Fertilisation

what is involved in oocyte insemination

A
  • 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
61
Q

In Vitro Fertilisation

when is Intracytoplasmic sperm injection (ICSI used

A

mainly for male factor infertility, where there are a reduced number or quality of sperm

62
Q

In Vitro Fertilisation

what happens in intracytoplasmic sperm injection (ICSI)

A
  • semen sample is produced,
  • the highest quality sperm are isolated
  • and injected directly into the cytoplasm of the egg.
63
Q

In Vitro Fertilisation

what happens in embryo culture

A
  • left in an incubator and observed over 2 – 5 days

- monitored until they reach the blastocyst stage

64
Q

In Vitro Fertilisation

what happens in embryo transfer

A
  • highest quality embryos are selected for transfer
  • catheter inserted under US guidance thru cervix into uterus
  • 1 embryo transferred
65
Q

In Vitro Fertilisation

when is a pregnancy test performed

A

around day 16 after egg collection

66
Q

In Vitro Fertilisation

why is progesterone vaginal suppositories given from the time of oocyte collection until 8 – 10 weeks gestation

A

to mimic the progesterone that would be released by the corpus luteum during a typical pregnancy

67
Q

In Vitro Fertilisation

complications relating to the overall process

A
  • failure
  • multiple pregnancy
  • ectopic pregnancy
  • ovarian hyperstimulation syndrome
68
Q

In Vitro Fertilisation

complications relating to the egg collection procedure

A
  • pain
  • bleeding
  • pelvic infection
  • damage to the bladder or bowel
69
Q

Ovarian Hyperstimulation Syndrome

what is it

A

a complication of ovarian stimulation during IVF

associated w/ use of hCG to mature the follicles during the final steps of ovarian stimulation

70
Q

Ovarian Hyperstimulation Syndrome

pathophysiology

A
  • 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
71
Q

Ovarian Hyperstimulation Syndrome

why is there raised renin level

A

activation of the RAAS

renin level correlates with the severity of the condition

72
Q

Ovarian Hyperstimulation Syndrome

RFs

A
  • Younger age
  • Lower BMI
  • Raised anti-Müllerian hormone
  • Higher antral follicle count
  • PCOS
  • Raised oestrogen levels during ovarian stimulation
73
Q

Ovarian Hyperstimulation Syndrome

prevention

A

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)
74
Q

Ovarian Hyperstimulation Syndrome

what strategies are used in high risk women to reduce the risk

A
  • 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)
75
Q

Ovarian Hyperstimulation Syndrome

early OHSS presents within how many days of the hCG injection

76
Q

Ovarian Hyperstimulation Syndrome

late OHSS presents within how many days of the hCG injection

77
Q

Ovarian Hyperstimulation Syndrome

features

A
  • 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)
78
Q

Ovarian Hyperstimulation Syndrome

severity: mild

A

abdo pain + bloating

79
Q

Ovarian Hyperstimulation Syndrome

severity: moderate

A

N+V w/ ascites seen on US

80
Q

Ovarian Hyperstimulation Syndrome

severity: severe

A
  • ascites
  • low urine output
  • low serum albumin
  • high potassium
  • raised haematocrit (>45%)
81
Q

Ovarian Hyperstimulation Syndrome

severity: critical

A
  • tense ascites
  • no urine output
  • thromboembolism
  • acute resp distress syndrome
82
Q

Ovarian Hyperstimulation Syndrome

mnx

A

supportive:

  • oral fluids
  • monitoring of urine output
  • LMWH
  • paracentesis of ascites if required
  • IV colloids (e.g. human albumin solution)
83
Q

Ovarian Hyperstimulation Syndrome

which patients may require admission

A

severe –> admit

critical –> ITU

84
Q

Ovarian Hyperstimulation Syndrome

what is haematocrit

A

the concentration of red blood cells in the blood

85
Q

Ovarian Hyperstimulation Syndrome

why is haematocrit monitored

A

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

86
Q

Ovarian Hyperstimulation Syndrome

what can raised haematocrit indicate

A

dehydration

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