Reproductive medicine

Question 1

28/F with history of 3 surgical TOP and one episode of Chlamydia infection complains of infertility after 1 year of unprotected sex. She is otherwise normal and her husband is ok.

What is the most probable cause of their infertility?

Answer 1

It is a secondary infertility.

• Causes: PID causing tubo-peritoneal defect?

Question 2

What investigations to do suspected PID patients?

Answer 2

• Pregnancy test first
• Blood tests: CBC: elevated WCC, CRP, ESR +/- LFT and clotting
• Blood culture and sensitivity

1. High vaginal swab x1 for Candida, Bacterial vaginosis, Trichomonas vaginalis

Endocervical swabs x2 for Neisseria Gonorrhoeae + Chlamydia trachomatis

2. Screen for other STDs
   - VDRL for syphilis
   - HIV serology
   - HBV, HCV
   - HPV (genital warts)
   - Pubic lice
3. Possible urinary tract infection (urinalysis, MSU for culture and sensitivity testing)

Question 3

for a patient with suspected PID for infertility?

Answer 3

• Laparoscopic chromotubation (Lap Dye)
• If chlamydia history: chlamydia antibody for tubo-peritoneal factor
• Hysteroscopy for uterine factors
• Ovulation assessment (mid-luteal phase progesterone, urinary LH surge) & early follicular phase LH/FSH/E2 for anovulation
• Semen analysis of husband x2
• Rubella antibody and MCV to rule out contraindications for pregnancy

Question 4

Advantages and disadvantages of hysterosalpingogram to laparoscopic chromotubation? (4)

Answer 4

:) :

1. less invasive than LC,
2. no GA risk and surgical risk

:( :
1. False positive due to contrast-induced tubal spasm

2. False negative as peritoneal disease and peritubal adhesions cannot be revealed

Question 5

If patient has severe tubal disease and extensive pelvic adhesion, management for infertility?

Answer 5

In vitro fertilization because of severe tubo-peritoneal factor

Question 6

How to calculate EDC?

e.g. LMP is 3/3

Answer 6

LMP +7 days + 9 months

LMP 3/3 > EDC = 10/12

Question 7

How to manage PID? What to do if failed first line Tx? (3)

Answer 7

1. Remove any IUCD if present
2. Give broad spectrum antibiotics
   - Metronidazole for anaerobics
   - Ceftriaxone for gonorrhea
   - Doxycycline for chlamydia
3. Laparoscopy if no response to antibiotics in presence of tubo-ovarian abscess

Question 8

What are the complications of PID?

Answer 8

1. Chronic pelvic pain
2. Infertility
3. Ectopic pregnancy

Question 9

What is the pearl index?

Answer 9

Total number of accidental pregnancies x100 / Total months of exposure to the contraceptive method

• reports the effectiveness of birth control method in terms of failure per 100 women years of exposure
• Less than 1/100 women per year
• 0.8 for copper IUCD; 0.2 for Mirena

Question 10

Give 4 reasons for the +ve PT results in spite of the use of IUCD.

Answer 10

1. Ectopic pregnancy
2. False positive
3. Molar pregnancy
4. Pregnancy

Question 11

For a lady with +ve PT but empty uterus, no adnexal mass, no free fluid, speculum: IUCD thread protruded from cervical os. What is the most important gyn condition has to be ruled out?

What is your management?

Answer 11

Ectopic pregnancy

• Admit the patient
• Monitor vitals, resuscitate if necessary
• Ix: serial betaHCG monitoring, CBC and L/RFT, clotting profile, cross match;

Depending on the hemodynamic status and L/RFT, give methotrexate if ectopic pregnancy is confirmed

Question 12

If patient has trichomonas vaginitis confirmed after vaginal swab, what is the treatment?

How to counsel the patient?

Answer 12

Tx: antibiotics: oral metronidazole 2g single dose

Counsel:

• It is a STD, advice STD screening
• Treat sexual partner as well
• Educate on prevention of STD
• TVS for tubo-ovarian abscess, admit if positive