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Human Development 2 PBL > PBL 1 > Flashcards

PBL 1 Flashcards

1
Q

Define the term subfertility

A

Defined as the inability to conceive for 12 months (up to 24 months) after commencing unprotected regular intercourse.

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2
Q

How many couples conceive in the period of 24 months

A
  • 80 percent conceive in the first year

- then out of the remains 20%, 50% conceive in the next year

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3
Q

what are the types of subferitlity

A

primary subfertility

secondary subfertility

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4
Q

define primary subfertility

A

no previous pregnancy

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5
Q

define secondary subferitlity

A

previous pregnancy (whatever the outcome).

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6
Q

what is the monthly probability of pregnancy

A

0.4 (reciprocal of average time required for conception in months).

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7
Q

name maternal causes of subfertility

A
  • pelvic inflammatory disease
  • endometriosis
  • fibroids
  • PCOS
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8
Q

what can subfertility be due to

A
  • male
  • female
  • combined factors
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9
Q

name different causes of subferilityt

A
  • ovulatory causes (25%)
  • tubular and uterine causes (30%)
  • male factors (30%)
  • unexplained subfertility (20%)
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10
Q

what are the three types of ovulatory causes

A

Type 1: Hypopituitary failure e.g. anorexia.

Type 2: Hypopituitary dysfunction e.g. PCOS, Hyperprolactinaemia

Type 3: Ovarian Failure (Premature OF if under 40 years).

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11
Q

describe how you manage type 1 hypopituitary failure

A

Type 1: Hypopituitary failure  anorexia.
• Management  increase weight, decrease exercise
o Consider pulsatile GnRH.

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12
Q

what is the most common cause of anovultaroy infertility

A

PCOS (polycystic ovarian syndrome)

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13
Q

what is PCOS characterised by

A

mild obesity

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14
Q

what is the diagnostic criteria for PCOS

A

• Oligomenorrhea (infrequent menstrual periods) OR amenorrhea (absent).
• Clinical hyoerandrogenaemia (hirsutism and acne).
o Raised LH with normal FSH, raised testosterone.
• Polycystic ovaries on ultrasound (>12 follicles measuring between 2 and 9mm diameter).
o And/or ovarian volume >10ml.

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15
Q

what is the difference between olgiomenorrhea and amenorrhea

A

• Oligomenorrhea (infrequent menstrual periods) OR amenorrhea (absent).

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16
Q

what is the cause of PCOS

A
  • believed due to be because of insulin resistance
  • this leads to hyperinsulinaemia
  • and increased androgen production of theca cells
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17
Q

how do you manage PCOS if the patient wants of conceive

A
  • weight loss if the patient is overweight
  • clomiphene; ovulation induction

surgery

  • ovarian drilling
  • wedge resection
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18
Q

how do you manage PCOS if the patient does not want to conceive

A
  • low contraceptive pills (restore menstural regulatory)
  • metformin
  • anti-androgens (such as cyproterone acetate)
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19
Q

what does metformin benefit

A
  • metformin seems to be benefiting the women undergoing IVF treatment
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20
Q

describe ovarain failure

A

Type 3: Ovarian Failure (Premature OF if under 40 years).
• OF involves persistent FSH raised.
• Management: donor eggs/alternative parenting.

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21
Q

what is pelvic inflammatory disease

A

• Severe inflammation of the peritoneal cavity caused by infection spreading from the vagina and cervix to the uterus, oviducts (Fallopian Tubes), ovaries and pelvic area

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22
Q

what is the diagnostic criteria of pelvic inflammatory disease

A
  • May be asymptomatic
  • Pelvic pain, dyspareunia (painful sexual intercourse), fever.
  • Cervical excitation: touching the cervix causes painful reaction.
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23
Q

what are the causes of pelvic inflammatory disease

A

STIs such as chlamydia (C. trachomatis) and gonorrhoea (Neisseria gonorrhoeae

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24
Q

what is the management of pelvic inflammatory disease

A

Management: antibiotics, rest and abstinence

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25
Q

what is endometriosis

A

• Presence of tissue histologically like endometrium outside the uterine cavity

26
Q

what is the diagnostic criteria of endometriosis

A
  • Pain
  • Dysmenorrhoea (painful menstruation).
  • Menorrhagia (abnormally heavy bleeding)
  • Dyspareunia (difficult/painful sexual intercourse).
27
Q

what is the management of endometriosis

A
  • NSAIDs
  • COPC (combined oral contraceptive pill)
  • GnRH Agonists
  • Surgery
28
Q

what are fibroids

A

• Benign tumours of smooth muscle of the myometrium (uterine leiomyoma).

29
Q

what are the symptoms of fibroids

A

o Complain of heavy, regular periods.

o Can grow to cause menorrhagia, dyspareunia.

30
Q

How do you treat fibroids

A

Treatment:
• Nothing.
• Medical: analgesia, COCP, progesterone intra-uterine devices.
• Radiological: embolization, radio-frequency ablation.
• Surgery: hysterectomy, uterine artery ligation

31
Q

What are the different locations of fibroids

A

submucosal, subserosal, intramural

32
Q

give examples of tubule and uterine causes of infertility

A
  • pelvic inflammatory disease
  • endometriosis
  • fibroids
33
Q

what are male causes of subfertility

A
  • Testicular - infection, cancer, surgical, congenital and trauma
  • azoospermia - absence of motile sperm
  • reversal of vasectomy
  • ejaculatory problems (retrograde and premature)
  • hypogonadism
34
Q

what are cortical problems

A
  • Dyspareunia (painful sexual intercourse).

* Coital Frequency <3 times a week (3-4%).

35
Q

describe unexplained infertility

A

• Do not offer clomiphene: no increased chance of pregnancy/live birth.
o Continue having regular unprotected intercourse.
 Offer IV after 2 years

36
Q

what drugs are linked to infertility

A

Female: long-term NSAID use, neuroleptics, spironolactone, Depo-Provera.

Male: anabolic steroids, chemotherapy.

37
Q

what do you ask in then istory of someone who is infertile

A 
o	Female: 
	Menstrual history, 
	Previous pregnancies, 
	Galactorrhoea (excessive/inappropriate production of milk), hirsutism
	Previous contraceptive history.

o Male: check for history of mumps orchitis,
 Occupation: excess heat, radiation, toxic chemicals, sedentary (too much time/inactive) job, tight-fitting pants.
 Abuse: of cigarettes, alcohol or substance

38
Q

what do you look for in a physical examination of infertility

A
  • Female: endocrine/systemic diseases/hirsutism, pelvic tumours, fibroids, cysts, genital abnormalities.
  • Male: endocrine/systemic diseases, lack of virilisation, small testicular size, epididymal cysts.
39
Q

describe how a semen analysis should be performed

A
  • Should be performed after three days’ abstinence.

* To confirm abnormality, tests should be repeated 3 times, each after month’s interval.

40
Q

what tests can be used for ovulation

A

Basal Body Temperature Chart

Pulsatile LH Secretion

41
Q

when does LH peak

A

• Reaches a peak 36hrs before ovulating.
• Can be determined in urine using simple homing testing kits.
o Can be used to time sexual intercourse.

42
Q

when must fertilisation occur

A

Fertilisation must occur 12-24 hours after ovulation (ovum only survives for 24 hours).

43
Q

what confirms pregnancy in progesterone

A

Luteal Phase Plasma Progesterone Level

• If over >= 30 nmol/ml confirms.

44
Q

what can test tubal potency and pelvic normality

A

• Assessed by ultrasonography, hysteroalpinography, hysteroscopy and/or laparoscopy/dye injection.

45
Q

what does a Kremer test test for

A

Check for cervical hostility

46
Q

what are the 3 phases of the menstural cycle

A
  • Menstrual phase (day 1-5)
  • Proliferative phase (day 6-14)
  • secretory phase (day 15-28)
47
Q

describe the three phases of the menstrual cycle

A 
Menstrual phase (day 1-5): 
•	Due to withdrawal of steroid support (oestrogen/progesterone) the endometrium collapses. 
•	Endometrium is shed with blood from ruptured arteries (blood loss: 50-150ml). 
Proliferative phase (day 6-14): 
•	Oestrogen from mature follicle stimulates thickening of the endometrium. 
•	Glands/spinal arteries form. 
•	Oestrogen also causes the growth of progesterone receptors on endometrial cells. 
Secretory phase (day 15-28):
•	Progesterone from corpus luteum: acts on endometrium. Enlargement of glands  secret mucus and glycogen in preparation for implantation of fertilised oocyte. 
•	No fertilisation = corpus luteum degenerates  corpus albicans. Progesterone levels fall
48
Q

what are the three phases of the ovarian cycle

A
  • follicular phase - day 1 to 10
  • ovulatory phase - days 11 to 14
  • luteal phase days 15-18
49
Q

describe the three phases of the ovarian cycle

A

Follicular phase: days 1 to 10
• 5-12 primordial follicles stimulated each month: one grows and matures.
• GnRH secreted from hypothalamus: stimulates anterior pituitary to secrete LH and FSH.
o These stimulates follicle to grow.
• Mature follicle secretes oestrogen.
o Inhibits further LH and FSH secretion by anterior pituitary (negative feedback).
o Stimulates growth of endometrium.

Ovulatory phase: days 11 to 14
• Negative feedback is temporary: oestrogen stimulates HPA resulting in burst of LH and FSH.
o Completion of meiosis I, onset of meiosis II in the oocyte.

Luteal phase: days 15 to 18
• Granulosa cells of mature follicle divide and form the corpus luteum
• Secretes progesterone and oestrogen. Prepares uterine endometrium for implantation

50
Q

what does Prempak C do

A

Includes oestrogen and progesterone (combined hormonal replacement theraphy).

51
Q

what is mandatory to do before treating subferitlity

A

(!) Before treatment it is mandatory to ensure women is immune to rubella infection.
• If rubella levels are low = immunize and advise against pregnancy for at least 3 months.

52
Q

How do you treat ovulation therapy

A
  • Treat using oral clomiphene citrate

* (If unsuccessful): human menopausal gonadotrophins.

53
Q

how do you monitor treatment of ovulation therapy

A

(!) Monitoring of these include transvaginal ultrasound (observe follicular) and serum oestradiol measurements to reduce the risks of multiple pregnancy ovarian hyperstimulation syndrome.

NOTE: tubal microsurgery is advocated by some as first-line treatment for tubal subfertility.
• Other prefer in-vitro fertilisation.

54
Q

what is IUI

A

Intrauterine Insemination (IUI)

55
Q

how does IUI work

A

• Sperm is separated in lab, removal of slower speed sperm before partner is inseminated.
o Insemination takes place day 12-16.
o If using ovarian stimulating drugs: use ultrasound.

56
Q

Who is IUI offered to

A

o People unable to have intercourse.
o Required specific consideration (HIV)
o Same sex relationships.

57
Q

how long is IUI tried for

A

• Tried for 12 cycles before IVF.

58
Q

who is IVF offered to

A

• Is offered to:
o Women under 40 who have no conceived after 2 years of unprotected intercourse.
 Offer 3 full cycles.

o Women 40-42 offered one cycle if:
 Never had IVF.
 6 or more UII cycles.
 No evidence of low ovarian reserve.

59
Q

what is ovarian hyper stimulation syndrome

A

: Ovarian Hyper Stimulation Syndrome

• Consequence of drugs sued to stimulate ovarian function.

60
Q

what is ICSI

A

• Single sperm injected directly into egg.

61
Q

who is ICSI offered to

A

o Severe deficits in semen quality
o Obstructive and non-obstructive azoospermia.
o Failure of IVF treatment.
• Improves fertilisation rates vs IVF, but pregnancy rate is not better

62
Q

what is post code variation

A

The situation with NHS funding for fertility treatment is very much a “treatment by
postcode” situation with PCTs in England making their own decisions on the level of
funding, if any, they put towards fertility treatment resulting in huge variations.

Human Development 2 PBL (6 decks)

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