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OG OSCE > OG Case 13 - Infertility > Flashcards

OG Case 13 - Infertility Flashcards

1
Q

Define infertility?

A

Failure to conceive after 12 months of unprotected intercourse.

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2
Q

Primary infertility?

A

Couple who has never been able to conceive.

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3
Q

Secondary infertility?

A

Find it difficult to conceive having already conceived in the past (could have had term pregnancy or may have experienced miscarriage).

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4
Q

How many couples experience infertility?

A

1 in 5.

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5
Q

What is fecundity?

A

The capacity to conceive and is measures as the monthly probability of conception.

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6
Q

What is the average monthly chance of conceiving in normal fertile couples?

A

20%.

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7
Q

What is the average duration for a fertile couple to conceive?

A

3 months.

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8
Q

What are the lifestyle factors that affect fecundity?

A
  1. Smoking - damages eggs, fallopian tubes, sperm, affects hormones in men/women, miscarriage risk, ectopic pregnancy.
  2. Moderate/heavy alcohol intake.
  3. Weight - high and low BMI.
  4. Exercise - none or excessive.
  5. Medication - steroids.
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9
Q

What are the causes of infertility?

A
  • 33% male factors.
  • 20% anovulation.
  • 15% tubal factors.
  • 10% endometriosis.
  • 5-10% cervical factors.
  • 15% unexplained.
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10
Q

What are the female causes of infertility in a female?

A
  1. Anovulation.
  2. Tubal factors.
  3. Cervical factors.
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11
Q

What can be causes of anovulation?

A
  1. Premature ovarian failure.
  2. PCOS.
  3. Hypothalamic/pituitary insufficiency.
  4. Hyperprolactinaemia.
  5. Metabolic disease (thyroid, renal, liver, underweight/obese).
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12
Q

What can be causes of tubal factors?

A
  1. PID (1 episode 10%, 3 episodes 50%).
  2. Previous ecctopic pregnancy.
  3. Adhesions, endometriosis.
  4. Peritoneal infections.
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13
Q

What can be causes of cervical factors?

A
  1. Congenital.
  2. Infection.
  3. Post-surgery.
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14
Q

What topics do you cover in the female infertility history?

A
  1. General hx - age, BMI, ethnicity, occupation/environment, folate in diet, smoking, drugs, EtOH.
  2. Endocrine - acne, hirsutism, dysmenorrhoea, galactorrhea, thyroid, weight gain.
  3. Intercourse - timing (in relation to ovulation) and frequency (>2x/month).
  4. Menstrual history - period regularity and frequency, anovulatory periods, signs of androgen excess, STI/PID, heavy bleeding, structural abnormalities.
  5. Past obstetric history - pregnancies, miscarriage, TOP, gravida/parity.
  6. Contraception.
  7. PMHx - fertility, chromosomal disorders.
  8. SHx - smoking, drugs, stress, libido.
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15
Q

What is the infertile female examination?

A
  1. General inspection.
  2. Height, weight, BMI.
  3. Vitals - HR, BP, RR, Temp (increases 0.3 degrees post-ovulation), SaO2.
  4. Endocrine/systemic disease - PCOS (evidence of hirsutism, acne, alopecia, striae).
  5. Abdomen - shape, scars, tenderness, striae.
  6. Pelvis -external genitalia, speculum (cervix), +/- smear, pipelle, HVS/endocyx swab, bimanual (uterine size, tenderness, adnexal masses).
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16
Q

What investigations do you do for an infertile female?

A
  1. Hep B, rubella, chlamydia, gonorrhoea screen.
  2. FBC.
  3. Hormone.
  4. USS - view follicle development or change to secretory endometrium, fibroids, endometriosis, masses, PCOS.
  5. Laparoscopy/hysterosalpingogram - assess tubal patency.
  6. Prolactin - produced by pituitary, increased levels interfere with ovarian function.
17
Q

What are the hormones that you test?

A
  1. Day 2-4 FSH/LH (LH is elevated days 2-5).
  2. Day 21 progesterone (mid luteal rise >30mmol/L in 3 cycles).
  3. Testosterone.
  4. LH:FSH ratio.
  5. TFT - hypothyroidism.
  6. Prolactin - produced by pituitary, increased levels interfere with ovarian function.
18
Q

What are the causes of infertility in males?

A
  1. Sperm.
  2. Anatomical.
  3. Endocrine.
  4. Sexual dysfunction.
19
Q

What are the causes of infertility due to sperm?

A
  1. Abnormal spermatogenesis - secondary to mumps, orchitis, chromosomal abnormalities, chemical/radiation exposure.
  2. Oligospermia/azoospermia.
  3. Abnormal morphology or motility.
20
Q

What are the anatomical causes?

A
  1. congenital.
  2. Obstruction of vas deferens.
  3. Varicocele - varicosities in spermatic cord veins.
  4. secondary to infection - mumps, STIs, prostatitis.
  5. Surgery or trauma.
21
Q

What are the endocrine causes?

A
  1. Hyperprolactinaemia.
  2. Hypothalamic or pituitary failure - tumour, radiation or surgery.
  3. Exogenous androgens.
  4. Adrenal hyperplasia.
22
Q

What topics do you cover in the infertile male history?

A
  1. Intercourse - frequency.
  2. Erection/ejaculation problems.
  3. Pubertal development.
  4. Previous fatherhood.
  5. Previous STI.
  6. Previous surgery - especially GU tract.
  7. SHx - smoking, EtOH, environmental toxins, illicit drug use.
23
Q

What is the infertile male examination?

A
  1. Evidence of gynaecomastia, eunuchoidal features (testes are present but fail to function normally; may be of gonadal or pituitary origin).
  2. Secondary sexual characteristics.
  3. Genital examination (particularly testicular volume/size, vas deferens palpation).
24
Q

What investigations do you do for an infertile male?

A
  1. Semen analysis:
    - volume >2mL.
    - density >20mil/mL.
    - motility >50%.
    - normal morphology >70%.
  2. Blood tests:
    - FSH (primary testicular failure, pituitary dysfxn).
    - Testosterone + LH (androgen deficiency).
    - Karyotyping (exclude chromosomal abnormality).
  3. Toehr swabs for chlamydia and gonorrhoea, post-coital test (>20 motile sperm/HPF).
25
Q

How do you manage infertility?

A
  1. Depends on aetiology.
  2. General measures:
    - coital timing (every 2 days in peri-ovulatory period, days 12-16).
  3. Emotional support.
  4. Lifestyle factors - stop smoking, weight loss, healthy diet, caffeine reduction.
26
Q

What are specific measures for PCOS?

A
  1. Weight loss.
  2. Clomiphene citrate (anti-oestrogen, increases FSH in early follicular phase).
  3. Metformin (improves insulin sensitivity).
  4. Recombinant FSH (direct ovarian stimulation, risk of multiple pregnancy).
27
Q

What are specific measures for tubal disease?

A

Hysterosalpingogram, manual removal or balloon tuboplasty, IVF if severe.

28
Q

What are specific measures for endometriosis?

A

IVF.

OG OSCE (2 decks)

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