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Year 4 - O&G > O&G - Infertility > Flashcards

O&G - Infertility Flashcards

1
Q

What is infertility?

A

Infertility is

the period of time people have been trying to conceive without success after which formal investigation is justified and possible treatment implemented

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2
Q

When taking a Hx from pt with fertility issues what questions / factors are important?

A
  • Age
  • How long trying to concieve?
  • Frequency of intercourse (every 2-3 days is optimal)
  • Past pregnancies / births (with/without current partner)
  • Contraception - when stopped? what type?
  • Menstrual Hx - regularity, LMP?
  • Smear Hx
  • Galactorrhoea or hirsutism
  • Systemic conditions e.g. diabetes, thyroid, IBD
  • Excessive exercise or weight loss?
  • Hx of STIs
  • Hx of PID
  • Hx of pelvic / tubal surgery
  • PMH
  • DH
  • SH - occupation (pesticides, solvents), smoking, alcohol
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3
Q

When should a woman be referred to a specialist for subfertility issues?

A

After at least 1-year of frequent UPSI (~ every 2-3 days)

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4
Q

What issues might prompt you to to refer a woman with fertility issues soon than normal (e.g. > 1-year UPSI)?

A

Consider more prompt investigation / referral for subfertility if:

  • Age > 35-yrs
  • Known fetility issues
  • Anovulatory cycles
  • Severe endometriosis
  • Previous PID
  • Malignancy
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5
Q

What % of couples will conceive after 1-year and 2-years of UPSI?

A

84% conceive after 1-year UPSI

92% conceive after 2-years UPSI

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6
Q

Anovulation can be cause by primary ovarian failure or

secondary ovarian disorders - give some exmaples of each.

A

Primary Ovarian Failure:

  • Premature ovarian failure (ovaries stop working < 40-yrs)
  • Turner’s syndrome (45XO - hypogonadism)
  • Autoimmune
  • Iatrogenic e.g. surgery or chemo

Secondary Ovarian disorders:

  • PCOS
  • Excessive weight loss or exercise
  • Hypopituitarism e.g. tumour, trauma, surgery
  • Kallman’s syndrome (anosmia & hypogonadotrophic hypogonadism)
  • Hyperprolactinaemia
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7
Q

What is Primary Amenorrhoea?

A

Failure to start menses by age 16-yrs

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8
Q

What are some causes of primary amenorrhoea?

A

Primary Amenorrhoea causes:

  • Turner’s syndrome (45 XO)
  • Testicular feminisation - when an XY individual becomes resistant to androgens due to abnormalities of X-chromosome –> female phenotype
  • Congenital adrenal hyperplasia (caused by autosomal recessive disorders causing ↓ adrenal steroid –> ↑ ACTH –> ↑ adrenal androgens –> masculinization of female)
  • Congenital malformations of the genital tract
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9
Q

What are some causes of secondary amenorrhoea?

A

Secondary Amenorrhoea causes:

  1. Hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
  2. Polycystic ovarian syndrome (PCOS)
  3. Hyperprolactinaemia e.g. prolactinoma (pituitary adenoma) - ↑ prolactin –> inhibits secretion of GnRH from hypothalamus –> ↓ FSH + LH
  4. Premature ovarian failure
  5. Thyroid disorder - either hyper or hypo
  6. Sheehan’s syndrome - hypopituitarism due to ischaemic necrosis due to blood loss during/after childbirth
  7. Asherman’s syndrome (intrauterine adhesions)
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10
Q

What is premature ovarian failure, also called primary ovarian insufficiency?

A

When a woman’s ovaries stop functioning normally before she is 40

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11
Q

What can cause premature ovarian failure (POF)?

A

Causes of POF:

  • idiopathic (most common)
  • chemotherapy
  • radiation
  • autoimmune
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12
Q

What are the features of POF?

A

Features of POF:

  1. Climacteric symptoms: hot flushes, night sweats
    • Climacteric = period of life when fertility decline in women (i.e. menopause)
  2. Infertility
  3. 2ndary amenorrhoea
  4. ↑ FSH + LH
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13
Q

How frequently should we advise pts trying to concieve to have UPSI?

A

UPSI every 2-3 days

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14
Q

What advise should we give couples trying to conceive?

A
  1. UPSI every 2-3 days
  2. < 1 or 2 units of alcohol once or twice per week
    • Men - alcohol < 3-4 units per day and < 14/week
  3. Smoking cessation (mum & dad)
  4. Recreational drug cessation (mum & dad)
  5. Weight loss - aim for BMI < 25 (men & women)
    • Women BMI < 19 –> aim to gain weight
  6. Take folic acid - 0.4 mg (or 5mg if Hx of NTD, diabetes or epilepsy)
  7. Caffeine is fine
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15
Q

How can we confirm that a woman is ovulating?

A
  1. Regular menstrual cycle - indicator that ovulation is occuring normally
  2. Measure serum progesterone 7-days post-ovulation / 7-days prior to next expected period (not done if cycle is regular)
    • Progesterone levels should peak 7-days after ovulation due to corpus luteum production - so if high then is evidence of ovulation ~ day 21 in cycle
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16
Q

Measuring serum FSH, LH and Oestradiol can be used to determine where in the HPG axis a pathology can be causing fertility issues. For each of the following state whether FSH, LH and Oestradiol will be high or low or normal.

  • Hypothalamic / pituitary dysfunction
  • Ovarian pathology
  • Premature ovarian failure
A
  • Hypothalamic / pituitary dysfunction (e.g. GnRH deficiency or excessive weight loss or exessive exercise, hyperprolactinaemia)
    • FSH & LH & Oestradiol = low
  • Ovarian pathology e.g. PCOS:
    • FSH = normal
    • LH = ↑
    • Oestradiol = normal
  • Premature ovarian failure:
    • FSH = ↑
    • LH = ↑
    • Oestradiol = ↓
17
Q

What is the best marker for Ovarian Reserve testing?

A

AMH - anti-mullerian hormone

18
Q

What is Ovarian reserve?

A

It is the capacity of the ovary to provide egg cells capable of fertilization

19
Q

Where is AMH produced?

A

Immature, pre-antral and antral follicles

Antrum = fluid filled cavity of oocyte

20
Q

As part of serum progesterone analysis what should be done for the following measurements?

  • < 16 nmol/l
  • 16 - 30 nmol/l
  • > 30 nmol/l
A
  • < 16 nmol/l –> repeat, if consistently low then refer
  • 16 - 30 nmol/l –> repeat
  • > 30 nmol/l –> indicates ovulation
21
Q

What investigations might be done in cases of subfertility?

A
  1. Semen analysis - all males!
    • Abstinence for 2-5 days (not > 7) then sample (repeat in 3-months if abnormal)
  2. Serum progesterone (if cycle not regular) to confirm ovulation
  3. AMH - indicates ovarian reserve
  4. Prolactin - if woman has ovulatory disorder, galactorrhoea or pituitary tumour
  5. TFT - only if thyroid symptoms
  6. Hysterosalpingography (HSG) - if not hx of PID, ectopics or endometriosis –> reliable test to rule out tubal occlusion
  7. Transvaginal US - assess uterus + ovaries e.g. cysts, fibroids etc.
  8. HIV, Hep B and Hep C
  9. Rubella status - if woman is susceptible then vaccinate (do no conceive in < 1-month after vaccination)
  10. Chlamydia screen - if +ve give Abx and give Abx before uterine instrumentation if not screened
22
Q

What elements are analysed on semen analysis and what is considered normal?

A

Semen analysis:

  • Semen volume: > 1.5 ml
  • pH: > 7.2
  • Sperm concentration: > 15 million per ml
  • Total sperm no. > 39 million per ejaculate
  • Total motility: > 40% motile or 32% or more with progressive motility
  • Vitality: > 58% live spermatozoa
  • Sperm morphology: > 4% with normal form
23
Q

Name 4 factors that influence spermatogenesis.

A
  1. Body-building drugs
  2. Smoking
  3. Male obesity
  4. Alcohol
24
Q

What is PCOS?

A

Polycystic ovarian syndrome:

  • Commonest endocrine disorder in women
  • Causes ~80% of anovulatory subfertility
  • Cause not fully understood:
    • Genetic elements
    • Insulin resistance –> hyperinsulinaemia
    • Hyperandrogenism (↑ ovarian androgen section)
    • Obesity
25
Q

What are the Rotterdam Diagnostic criteria for PCOS?

A

PCOS if 2 of the following are present + exclusion of other disorders:

  1. Irregular or absent ovulations
  2. Polycystic ovaries - on pelvic US ≥ 12 antral follicles on one ovary, ovarian volume > 10 ml
  3. Signs of hyperandrogenism:
    • Acne
    • Hirutism
    • Alopecia
26
Q

What are the features of PCOS?

A
  1. Subfertility / infertility
  2. Amenorrhoea or Oligomenorrhea (infrequent periods)
  3. Hyperandrogenism:
    • Acne
    • Hirsutism
    • Alopecia
  4. Obesity
  5. Acanthosis Nigricans (due to hyperinsulinaemia due to insulin resistance)
27
Q

What investigations might you do in suspected PCOS?

A
  • General examination:
    • ↑ BMI
    • Hirsutism
    • Acne
    • Alopecia
    • Acanthosis Nigricans
  • Impaired glucose tolerance test
  • FSH, LH, prolactin, TFTs and testosterone
    • Hypersecretion of LH (~60% of cases) cause ↑ LH:FSH ratio (not diagnostic)
    • Prolactin - normal / slight ↑
    • Testosterone - normal / slight ↑ (is ↑ significantly then consider other diagnosis)
  • Pelvic US - looking for ↑ ovarian volume and ≥12 antral follicles on one ovary
28
Q

What are some complications of PCOS?

A
  • ↑ risk of T2DM
  • ↑ risk of gestational diabetes
  • HTN - more due to insulin resistance + obesity common in PCOS
  • Endometrial b- infrequent or absent periods can cause endometrial hyperplasia (managed via progesterone based contraception)
29
Q

How is PCOS managed?

A
  • Lifestyle management:
    • Weight loss - diet + exercise –> can help with menstrual regularity + subfertility
  • Hirsutism / Acne:
    • 1st line = COCP:
      • ↓ serum androgens
      • co-cyprindiol - provides antiandrogen effects + regular monthly bleed
    • 2nd line = topical eflornithine (anti-androgen)
    • 3rd line = spironolactone or flutamide or finasteride
  • Subfertility:
    • Ovulation induction with Clomifene (anti-oestrogen) or gonadotrophins
    • Laproscopic ovarian diathermy - can trigger ovulation
    • IVF
30
Q

Do women with polycystic ovaries have PCOS?

A

NO!

PCOS is polycystic ovaries and symptoms!

31
Q

What 3 investigations can be used for assesment of tubal patency?

A
  1. Hysterosalpingography (HSG)
    • Inject radio-opaque material into cervical canal, uterus and fallopian tubes visualised via fluroscopy (real-time x-rays)
    • Easily done
  2. Laproscopy + Dye test:
    • ‘Gold Standard’ - dye pushed through uterus + fallopian tubes and enters abdominal cavity (rate of flow viewed via laproscopy - then suctioned)
    • Done if pt has ↑ risk of adhesions or tubal pathologies e.g. due to past C-section or Hx of Chlamydia
    • Pelvic pathology e.g. endometriosis / adhesions can be treated during
    • Requires GA
    • Surgical risks
  3. Hysterosalpingo-contrast-sonography (HyCoSy):
    • US + galactose-containing contrast medium (forced/pumped into fallopian tube so it can be seen on US)
    • Similar sensitivity to HSG
    • No radiation
32
Q

What is Endometriosis?

A

Endometriosis = growth of ectopic endometrial tissue

outside the uterine cavity

  • ~10% of women of reproductive age have some degree of endometriosis
33
Q

What are the features of endometriosis?

A
  1. Chronic pelvic pain
  2. Dysmenorrhoea - pain often starts days before bleeding
  3. Deep dyspareunia (pain on intercourse)
  4. Subfertility
  5. Urinary symptoms e.g. dysuria, urgency, haematuria
  6. Dyschezia (painful bowel movements)
  7. Blood in stool (less common)
  8. Bimanual exam:
    • Adnexal masses (endometriomas) or tenderness
    • Posterior fornix nodules/tenderness
    • Recto-vaginal nodules
  9. May seen vaginal endometriotic lesions
34
Q

How is endometriosis diagnosed / investigated?

A

Laproscopy (gold standard)

  • Should not be performed in < 3-months of hormonal management (leads to underdiagnosis)
  • Laproscopy indicated by:
    • NSAID-resistant lower abdo pain / dysmenorrhoea
    • Pain + infertility investigation
    • Pain resulting in days off school/work
35
Q

How is Endometriosis managed?

A

Only manage if symptomatic!!

  • 1st line = NSAIDs +/- Paracetamol - if analgesia doesn’t help …
  • 2nd line = hormonal treatment IUS or COCP or Progesterone-only (e.g. pill, depo or implant)
    • Can also use GnRH agonist –> overstimulation of pituitary gland causes downregulation and thus de-sensitisation of pituitary to GnRH –> ↓ FSH + LH –> ↓ oestrogen –> pseudomenopause (but can’t be used in young women)
  • 3rd line = Laproscopic excision / laser treatment - all lesions > 3cm should be removed (rule out malignancy - rare)
    • Last line is hysterectomy + bilateral salpingo-oophrectomy
36
Q

What is ovarian hyperstimulation syndrome (OHSS)?

A

OHSS is a complication seen in some forms of infertility treatment e.g. intracytoplasmic sperm injection (ICSI) or IVF or rarely Clomifene therapy

  • Proposed that presence of multiple luteinized cysts –> high oestrogen + progesterone, but also ↑ vasoactive substances e.g. VEGF
  • Vasoactive substances –> ↑ membrane permeability –> loss of fluid from intravascular compartment

Features:

  • Abdo pain & bloating
  • Nausea & vomiting
  • Ascites
  • Oliguria (↓ urine output)
  • Haematocrit > 45%
37
Q

A 36 year old woman and her 38 year old partner present with primary female/ primary male/ primary couple subfertility. The woman’s periods are regular and she has no history to suggest a tubal factor. The semen analysis is normal.

What is the most appropriate plan?

  • Clomiphene citrate 50mg days 2-6 of the cycle for 6 months
  • Continue to try to conceive for a further 12 months and if unsuccessful, refer for IVF treatment
  • Proceed to IVF treatment
  • ​​​​​​​Stimulated IUI treatment (intrauterine insemination)
  • Unstimulated IUI treatment
A

Proceed to IVF treatment

  • Woman > 36-yrs –> proceed to IVF
  • IUI or clomiphene do NOT increase the chance of conception in cases of unexplained infertility

Year 4 - O&G (12 decks)

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