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RC ObGYN 2021 > REI > Flashcards

REI Flashcards

1
Q

What is the scoring system for hirsutism?

A 
Ferriman-Gallway score
>=8 excessive hair growth 
8-15 mild hirsutism 
16-25 moderate hirsutism 
>25 severe hirsutism

SOGC 350

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2
Q

What is the incidence of women of reproductive-age who are diagnosed with hirsutism?

A

5-10%

SOGC 350

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3
Q

What is non-classical congenital adrenal hyperplasia? What test would we order if we suspect it in a patient with hyperandrogenism hirsutism?

A

It is a partial deficiency of the 21-dehydroxylase enzyme
We would need to order 17-hydroxyprogesterone if we suspect it

SOGC 350

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4
Q

What are the incidences of moderate and severe OHSS after superovulation for IVF?

A

3-6% for moderate OHSS
0.1-2% for severe OHSS

Mild OHSS occurs in 20-33% of IVF cycles

SOGC 268

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5
Q

What is the mechanism by which OHSS occurs?

A

Systemic condition thought to result from vasoactive peptides released from granulosa cells in hyperstimulated ovaries
• Increase in vascular permeability resulting in fluid shift from intravascular to third space compartments (peritoneum or thoracic cavities)
• HCG shown to increase VEGF expression in human granulosa cells -> raises serum VEGF concentration

SOGC 268

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6
Q

Name the 8 risk factors for the development of OHSS.

A

Risk factors of OHSS
• Age <30 years old
• PCOS of high basal antral follicle count on US
• Rapidly rising or high serum estradiol
• Previous history of OHSS
• Large number of small follicles (8-12mm) seen on US during ovarian stimulation
• Use of hCG as opposed to progesterone for luteal phase support after IVF
• Large number of oocytes retrieved (>20)
• Early pregnancy

SOGC 268

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7
Q

What is the first sign of impending severe OHSS?

A

Abdominal bloating

SOGC 268

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8
Q

What are the criteria for critical OHSS?

A

1) tense ascites or pleura effusion
2) oliguria/anuria
3) hematocrit >55%
4) acute respiratory distress
5) thromboembolism
6) WBC>25

SOGC 268

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9
Q

What medications should be avoided in women with OHSS?

A

NSAIDS and diuretics

SOGC 268

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10
Q

Natural female fertility declines at what age

A

mid-30s

SOGC 346

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11
Q

Negative aspects of ART (4)

A
  1. Will not compensate for decline in natural fertility due to delayed child-bearing
  2. Invasive
  3. Expenseive
  4. Increased pregnancy complications for both mother + fetus with advancing maternal age

SOGC 346

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12
Q

How many oocytes in:

  • a 20wk fetus
  • a neonate
  • a pubertal girl
  • a woman at menopause
A

20wk: 6-7 million
birth: 1-2 million
puberty: 3-500 thousand
menopause: a few hundred

SOGC 346

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13
Q

How many ovulations in a reproductive lifetime

A

4-500; majority of the rest are lost through apoptosis

SOGC 346

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14
Q

Natural course of reproductive life as ovarian follicular pool decreases (5 steps)

A
  1. Infertility
  2. Sterility
  3. Cycle shortening
  4. Menstrual irregularity
  5. Menopause

SOGC 346

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15
Q

Optimal fertility age range

A

20-30

SOGC 346

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16
Q

Average age (and range) of menopause in Western countries

A

51 (40-60)

SOGC 346

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17
Q

Rate of premature ovarian failure (menopause < 40)

A

1%

SOGC 346

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18
Q

True/false: earlier loss of fertility is associated with earlier menopause

A

True

SOGC 346

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19
Q

How many years before menopause does child-bearing usually end?

A

10 years

SOGC 346

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20
Q

What cell makes inhibin-B, and in which phase of menstrual cycle

A

Granulosa cell in early follicular phase

SOGC 346

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21
Q

Describe physiology of transitioning to menopause

A

Decreasing # of follicles → decreasing inhibin-B → increasing FSH from loss of negative feedback

SOGC 346

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22
Q

Earliest sign of ovarian aging (lab test)

A

Rise in FSH

SOGC 346

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23
Q

Earliest sign of ovarian aging (clinical)

A

Cycle shortening (shorter follicular phase) due to earlier recruitment of a dominant follicle

SOGC 346

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24
Q

After cycle shortening, why do cycles get longer closer to menopause?

A

Ovulation is less consistent, leading to longer and more irregular cycles

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25
Q

Women whom are sterile at age 35 already have lower fecundity by what age

A

30

SOGC 346

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26
Q

How long after menopause is there still ovarian activity and estrogen production

A

At least 1 year after menopause

SOGC 346

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27
Q

Impact of smoking on reproductive potential (2)

A
  1. Decreases follicular pool
  2. Leads to earlier menopause

SOGC 346

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28
Q

Rate of aneuploidy in oocytes in stimulated cycles

  • age < 35
  • age 40
  • age 43
  • age > 45
A
  • < 35 = 10%
  • 40 = 30%
  • 43 = 40%
  • > 45 = 100%

SOGC 346

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29
Q

At the cellular level, why do rates of aneuploidy in oocytes increase with age?

A

More diffuse formation and function of spindles → chromosomes less tightly arranged → meiotic errors

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30
Q

Reasons for poorer oocyte quality with increasing age (5)

A
  1. Meiotic errors from poor spindle formation/function
  2. Oocyte selection process diminishes with age
  3. Less discrimination of dominant follicle selection (dominant follicle allowed to mature instead of undergo atresia)
  4. Cumulative damage to oocyte with age
  5. Decreasing quality of granulose cells

SOGC 346

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31
Q

Natural decline in birth rate begins at what age

A

35

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32
Q

Average age of last child (and range)

A

41 (23-51)

SOGC 346

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33
Q

Factors leading to decreased live birth rate later in life (5)

SOGC 346

A
  1. Desire to prevent pregnancy
  2. Coital frequency decreases
  3. Aging partners
  4. Medical conditions that affect live birth rate
  5. Fibroids and endometriosis more common in later reproductive years
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34
Q

Definition of fecundity rate

A

Rate at which a woman is able to conceive (how long it takes to get pregnant)

SOGC 346

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35
Q

True/false: fecundity rate decreases with age

A

True: younger women have a higher fecundity rate than older women

SOGC 346

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36
Q

% of women married in early 20s (vs. married in 40s) who remain childless

A

6% vs. 64%

SOGC 346

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37
Q

True/false: current ART success rates are able to compensate for loss in natural fertility that occurs with aging (e.g. 30 to 35)

A

False

SOGC 346

38
Q

Cumulative pregnancy rates after 12 IUI cycles by age:

  • < 30
  • 30+
A

< 30 → 62%
30+ → 44%

SOGC 346

39
Q

Live birth rate with IVF by age:

  • < 35
  • 35-39
  • 40+
A

< 35 → 41%
35-39 → 30.9%
40+ → 12.3%

SOGC 346

40
Q

True/false: age is the most significant prognostic factor for IVF success

A

True

SOGC 346

41
Q

True/false: age affects the endometrium’s response to hormonal stimulation

A

False: the age of recipient does not affect pregnancy rates in donor egg cycles

SOGC 346

42
Q

How soon after attempting to conceive should women > 35 be referred for infertility workup?

A

6 months (as opposed to 12 months in younger women)

SOGC 346

43
Q

True/false: ovarian reserve testing can predict infertility and/or time to infertility

A

False: it cannot do either of those

SOGC 346

44
Q

Ovarian reserve testing values correlate with what 2 things

A
  1. Egg quantity
  2. Response to ovarian stimulation

SOGC 346

45
Q

True/false: ovarian reserve testing values correlate well with oocyte quality

A

False

SOGC 346

46
Q

True/false: ovarian reserve testing values correlate well with pregnancy achieved with ART

A

False; however, very abnormal results (3% of women) are associated with lower pregnancy rates (<5%)

SOGC 346

47
Q

How should interpretation of ovarian reserve testing be used in clinical practice?

A

It should be used to counsel patients (offer oocyte donation to increase pregnancy rates), but it should not be used to exclude women from ART, as some women with abnormal tests still get pregnant

SOGC 346

48
Q

What are risk factors for decreased ovarian reserve, that would prompt you to do testing in women < 35 (5)

A
  1. Single ovary
  2. Previous ovarian surgery
  3. Poor response to FSH
  4. Previous chemo/radiation
  5. Unexplained infertility

SOGC 346

49
Q

List markers of ovarian reserve (6)

A
  1. Day 3 (basal) FSH
  2. Ovarian antral follicle count (early in cycle)
  3. Antimullerian hormone
  4. Clomiphene citrate challenge
  5. Inhibin-B
  6. Basal estradiol

SOGC 346

50
Q

Above what level of FSH denotes ovarian aging, and at what age does this usually happen

A

FSH > 14 IU/L
Usually age 35-40

SOGC 346

51
Q

Why does FSH rise with ovarian aging?

A

It goes up in response to loss of negative feedback from inhibin A and B

SOGC 346

52
Q

FSH as a marker of ovarian reserve is predictive of what 2 things

A
  1. Predictive of poor response to ovarian stimulation
  2. At extremely elevated levels, it is predictive of non-pregnancy

SOGC 346

53
Q

In what population does FSH have less predictive power as a marker of ovarian reserve

A

Women < 35

SOGC 346

54
Q

When should an ovarian antral follicle count be performed

A

Early in the menstrual cycle

SOGC 346

55
Q

What size are antral follicles

A

2-10 mm

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56
Q

Why is antral follicle count used as a marker of ovarian reserve

A

Antral follicles are sensitive to FSH, and are considered representative of the available follicular pool; they correlate with # of primordial follicles in the ovary

SOGC 346

57
Q

What makes antral follicle count less valuable as a marker of ovarian reserve

A

The proportion of antral follicles : total follicles may increase later in reproductive years, as the ovary allows a higher proportion of follicles to be selected

SOGC 346

58
Q

Antral follicle count as makers of ovarian reserve is predictive of what 2 things

A
  1. Predictor of menopause transition
  2. Predictor of ovarian response to stimulation
    (However, it is not a good predictor of pregnancy)

SOGC 346

59
Q

Where is antimullerian hormone made?

A

Produced by granulose cells of preantral and small antral follicles, but not by dominant follicles

SOGC 346

60
Q

When in the menstrual cycle should AMH be measured

A

At any point! Levels are consistent throughout the cycle

SOGC 346

61
Q

As a marker of ovarian reserve, what 1 thing does AMH level predict

A
  1. Provides moderate value in prediction of ovarian response in IVF
    (However, it is a poor predictor of pregnancy)

SOGC 346

62
Q

How do AMH levels correlate with AFC levels

A

AMH levels decrease with decreasing AFC

SOGC 346

63
Q

Describe clomiphene citrate challenge test

A

100 mg PO daily from days 5-9
Measure FSH level days 3 and 10
An adequate response is noted if the rise in FSH is suppressed by the release of estradiol and inhibin-B by developing follicles

SOGC 346

64
Q

How is clomiphene citrate challenge test more beneficial than other markers of ovarian reserve

A

There is no benefit to this test over basal FSH or AFC

SOGC 346

65
Q

How are inhibin-B and basal estradiol more beneficial than other markers of ovarian reserve

A

These tests are not more useful predictors of poor response or pregnancy than basal FSH

SOGC 346

66
Q

List 1 way estradiol works WITH FSH and 1 way it works AGAINST FSH as a marker of ovarian reserve

A

with: basal estradiol levels, when analyzed with FSH, can confirm correct timing in the menstrual cycle
against: elevated estradiol level may falsely suppress FSH levels

SOGC 346

67
Q

What are 2 distinct populations in which ovarian reserve testing may be considered

A
  1. Age 35+
  2. Age < 35 with risk factors for decreased ovarian reserve

SOGC 346

68
Q

What is the goal of treatment of age-related infertility

A

To decrease time to conception

SOGC 346

69
Q

What is the best treatment for age-related infertility

A

Oocyte donation

SOGC 346

70
Q

What are the success (pregnancy rates) of clomiphene citrate + IUI based on age

  • 38-40
  • 41-42
  • > 42
A
  • 38-40 → 7%
  • 41-42 → 4%
  • > 42 → 1%

SOGC 346

71
Q

What are the success (live birth rates) of gonadotropins + IUI based on age

  • 38-39
  • > 40
A
  • 38-39 → 6%
  • > 40 → 2%

SOGC 346

72
Q

What are live birth rates per cycle of IVF based on age

  • > 40
  • 42+
  • 45+
A
  • > 40 → 12.3%
  • 42+ → < 5%
  • 45+ → 0%

SOGC 346

73
Q

What are miscarriage rates with IVF based on age

  • 40-42
  • > 42
A
  • 40-42 → 43.1%
  • > 42 → 65.2%

SOGC 346

74
Q

What should be the threshold to transition from controlled ovarian hyperstimulation (COH) to IVF in patients > 40

A

May consider 1-2 cycles of COH, but should move on to IVF quickly if unsuccessful

SOGC 346

75
Q

True/false: oocyte donation may help achieve pregnancy in women who have already gone through menopause

A

True!

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76
Q

Outline the rules of the 2004 Assisted Human Reproduction Act

A
  • It regulates all reproductive technologies
  • It prohibits sale of eggs, sperm, or surrogacy services
  • Compensation to donors for receptacle expenses (e.g. prescriptions, parking) is allowable
  • Must rely on altruistic egg donors
  • May access donor banks in USA for frozen oocytes from anonymous donors

SOGC 346

77
Q

Between oocyte donor and oocyte recipient, whose age is more predictive of pregnancy rate

A

The age of the oocyte donor

SOGC 346

78
Q

What complications make oocyte donation to women > 50 controversial (5)

A
  1. Maternal death
  2. Hypertension
  3. Prematurity
  4. Fetal and neonatal death
  5. Operative delivery

SOGC 346

79
Q

What is the age limit for ART?

A

There is no age limit in Canada; however, guidelines recommend women > 45 have medical assessment and obstetrical consultation prior to treatment

SOGC 346

80
Q

What early pregnancy complications increase with age (3) (see text for rates)

A
  1. SAB (whether with or without ART)
  2. Rates of chromosomal anomalies
  3. Rates of Down syndrome

SOGC 346

81
Q

What later pregnancy complications increase with age (5) (see text for rates)

A
  1. Surgical delivery
  2. Gestational diabetes
  3. Preeclampsia
  4. IUGR
  5. Low birth weight

SOGC 346

82
Q

What preconceptional counselling/screening should be considered in women > 40 (3)

A
  1. Promotion of optimal health and weight
  2. Screen for hypertension
  3. Screen for diabetes

SOGC 346

83
Q

What physiologic parameter changes lead to paternal age-related fertility decline (4)

A
  1. Decline in testicular function, including testosterone levels
  2. Lower semen volume
  3. Lower sperm motility
  4. More abnormal sperm morphology

SOGC 346

84
Q

Does paternal age affect natural fertility?

A

1 study suggests that odds of conception decrease by 3% per year; other studies show only a small effect

SOGC 346

85
Q

Does paternal age affect IUI or IVF success?

A

1 study suggests paternal age > 35 may have an effect on IUI
Most studies suggest paternal age has no effect on IVF/ICSI. However, there is a significant decrease in rate of blastocyst embryo formation on day 5 and in # of cry–reservable embryos

SOGC 346

86
Q

What 3 autosomal dominant syndromes are associated with increasing paternal age

A
  1. Alport syndrome
  2. Achondroplasia
  3. Neurofibromatosis
    (However, absolute risk < 0.5%)

SOGC 346

87
Q

True/false: increasing paternal age impacts rates of preterm birth and low birth weight

A

Conflicting evidence

SOGC 346

88
Q

True/false; increasing paternal age is associated with greater risk of miscarriage

A

True: even when controlling for maternal age

SOGC 346

89
Q

What 2 neuropsychiatric disorders are associated with increasing paternal age (see text for rates)

A
  1. Autism spectrum disorder
  2. Schizophrenia

SOGC 346

90
Q

Should additional prenatal testing take place due to increased paternal age?

SOGC 346

A

No; however, men > 40 and their partners should be counselled about these potential risks when they are seeking pregnancy, although the risks remain small

RC ObGYN 2021 (11 decks)

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