Reproductive medicine Flashcards
What is needed to achieve a pregnancy?
Functioning menstrual cycle:
ovulation
endometrial thickening
Healthy fallopian tubes
Healthy sperm
What preconceptional advice is given to women?
Stop smoking
No alcohol intake
BMI < 19 and > 30 impact fertility
Impact of caffeine is still unclear
Complementary therapy - unclear benefit
Consider any occupational hazards
Stop recreational drug use
What preconceptional advice is given to men?
Stop smoking
Alcohol 3 – 4 units / week
BMI > 30 likely to reduce fertility
Elevated scrotal temperature is associated with reduced semen quality, but uncertain whether wearing loose-fitting underwear improves fertility
How often should sexual intercourse occur to optimise natural fertility?
Every 2-3 days
What preconceptional vitamin supplements are given to women?
Folic acid
(0.4mg/day OR 5mg/day)
Vitamin D
(10mcg/day)
When might 5mg/day of folic acid be given to women instead of 0.4mg?
Previous child with neural tube defect
Personal or family history of neural tube defect for either partner
Diabetes mellitus (type 1 and type 2)
Coeliac disease
BMI ≥ 30 kg/m2
Inherited haemoglobinopathies including carrier states (thalassemia trait)
Anti-folate medication – (sulpha drugs)
What are the four main categories of causes of infertility?
Disorders of ovulation
Male factors
Pelvic pathology
Unexplained
What are the three different WHO classifications of anovulatory infertility?
Group 1: hypothalamic pituitary failure
Group 2: hypothalamic-pituitary-ovarian dysfunction
Group 3: ovarian failure
(other causes: hyperprolacintaemia)
What is group 1 anovulatory infertility?
hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism).
(commonly athletes, dancers etc - BMI >19)
What is group 2 anovulatory infertility?
hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome).
What is group 3 anovulatory infertility?
Ovarian failure
What are oestrogen and FSH levels like in group 1 anovulatory infertility?
Oestrogen low
FSH low or normal
What are oestrogen and FSH levels like in group 2 anovulatory infertility?
Oestrogen normal
FSH normal
What are oestrogen and FSH levels like in group 3 anovulatory infertility?
Oestrogen low
FSH high
How would you manage someone who has a group 1 ovulation disorder?
If BMI < 19 - increase weight
if high levels of exercise - moderate exercise
treatment - gonadotrophin for ovulation induction
What is the female athlete triad that impacts fertility?
Low energy availability/eating disorders
Low bone mass
menstrual disturbance
What is the most common cause of group 2 anovulatory infertility?
PCOS
What is the triad of PCOS symptoms called? What are they?
Rotterdam criteria - need 2 of:
Polycystic ovaries on US
Oligo/anovulation
Clinical/biochemical hyperandrogenism
How would you manage anovulation in PCOS?
Consensus algorithm
FIRST LINE
If no ovulation: lifestyle +/- bariatric surgery
SECOND LINE
If no ovulation: Clomiphene citrate (CC) or letrozole
THIRD LINE
Gonadotrophins OR
CC + metformin OR
Laparoscopic ovarian diathermy
FOURTH LINE
IVF
If at any stage the woman starts ovulating, leave for 6-9 cycles to conceive naturally. If this doesn’t occur - IVF
What are the diagnostic criteria for group 3 ovulation disorders (Premature ovarian insufficiency)?
Oligo/amenorrhoea for at least 4 months
Elevated FSH level >25
on 2 occasions
> 4 weeks apart.
Patient <40yrs
What are some causes of premature ovarian insufficiency?
Turner syndrome Chromosomal material Fragile X Anti-adrenal antibodies Thyroid peroxidase antibodies
How would you manage group 3 (premature ovarian insufficiency) ovulation disorders?
Fertility treatment
Oocyte donation
HRT (prevent osteoporosis)
(no interventions to increase ovarian activity and natural conception rates)
What are some causes of pelvic pathology that could inhibit reproduction?
PID
Endometriosis
Past abdo/pelvic infection or surgery
How could you investigate pelvic causes for reduced fertility?
hysterosalpingography (low risk women)
hysterosalpingo-contrast-ultrasonogrpahy
GOLD STANDARD: LAPAROSCOPY
What should a male sperm count be? What is it called if this is not the case?
> =15 million/ml
Oligozoospermia
What should the progressive motility of male sperm be? What is it called if this is not the case?
> =32%
Asthenozoospermia
what is the lower limit of percentage of sperm with normal morphology, that is required for sufficient male fertility? What is it called if this is not achieved?
4%
Teratozoospermia
What are some causes of male infertility?
Idiopathic (most common)
Hypogonadism (medically treatable)
Genetic causes
Testicular trauma/surgery/developmental abnormalities
Obstructive (vasectomy/infection)
Anabolic steroids (not always reversible)
Previous chemotherapy
How is male infertility managed?
If there is sperm in the ejaculate: ICSI
If there isn’t sperm in the ejaculate: surgical sperm retrieval or donor sperm
How should unexplained infertility be managed?
Exclude all causes
Recommend 2 years of trying
IVF
(ovulation induction and intrauterine insemination are not of benefit)
When can IUI be used?
difficulty with sexual intervourse: physical disability
psychosexual issues
donor sperm
What is the process of IVF?
Egg production stimulated by hormone therapy (injections)
Eggs retrieved from woman’s body in minor surgical procedure under sedation
Sperm sample provided
Eggs and sperm combined in lab to allow fertilisation (if ICSI, pick best sperm and eject them on the same day)
Embryo left to grow for 2-6 days
Embryo with best chance of survival chosen
Fertilised embryo introduced into womb (procedure feels like a smear)
Medicines taken to give embryo best chance of survival
2 weeks later: PT
Ultrasound 3 weeks later
What is ovarian hyper stimulation syndrome (OHSS)?
Too much hormone given = some serious symptoms for women. Can be life-threatening.
What are some symptoms of mild OHSS?
Abdo bloating
Mild abdo pain
Ovarian size <8cm
What are some symptoms of moderate OHSS?
Abdo pain
nausea and vomiting
USS of ascites
Ovarian size 8-12
What are some symptoms of severe OHSS?
Clinical ascites oliguria hyponatraemia hyperkalaemia hypo-osmolality hypoprotinaemia ovarian size >12 cm
What are some symptoms of critical OHSS?
Tense ascites
Haematocrit >0.55
WCC >25000
Oliguria/anuria
If a woman in undergoing IVF and complains of abdo pain, nausea and vomiting and has signs of fluid retention, what would you suspect? How would you investigate and confirm diagnosis?
Ovarian hyperstimulation
Ultrasound pelvis and abdomen
Bloods
What advice can be given to men about fertility preservation? When should these be done
Post-pubertal boys and adults: sperm cryopreservation
Pre-Pubertal boys: currently no clinically advisable option
Advisable to discuss these options prior to therapy that potentially affects fertility:
chemo
radio
surgery: testicular, reproductive tract, retroperitoneal nerve plexus
What advice can be given to women about fertility preservation? When should these be done
GnRH analogies for ovarian suppression - been shown to have some success in women receiving chemo for breast cancer
oocyte/embryo cryopreservation
social egg freezing/anticipation of age-related decline in fertility
What are the risks of egg donation? How does age impact egg donation?
Hypertensive disorders of pregnancy
Pre-term birth
Low birth weight
Pregnancy > 40: increased maternal and foetal risks
