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GOSH > Reproductive medicine > Flashcards

Reproductive medicine Flashcards

1
Q

What is needed to achieve a pregnancy?

A

Functioning menstrual cycle:
ovulation
endometrial thickening

Healthy fallopian tubes

Healthy sperm

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2
Q

What preconceptional advice is given to women?

A

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

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3
Q

What preconceptional advice is given to men?

A

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

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4
Q

How often should sexual intercourse occur to optimise natural fertility?

A

Every 2-3 days

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5
Q

What preconceptional vitamin supplements are given to women?

A

Folic acid
(0.4mg/day OR 5mg/day)

Vitamin D
(10mcg/day)

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6
Q

When might 5mg/day of folic acid be given to women instead of 0.4mg?

A

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)

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7
Q

What are the four main categories of causes of infertility?

A

Disorders of ovulation
Male factors
Pelvic pathology
Unexplained

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8
Q

What are the three different WHO classifications of anovulatory infertility?

A

Group 1: hypothalamic pituitary failure

Group 2: hypothalamic-pituitary-ovarian dysfunction

Group 3: ovarian failure

(other causes: hyperprolacintaemia)

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9
Q

What is group 1 anovulatory infertility?

A

hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism).

(commonly athletes, dancers etc - BMI >19)

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10
Q

What is group 2 anovulatory infertility?

A

hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome).

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11
Q

What is group 3 anovulatory infertility?

A

Ovarian failure

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12
Q

What are oestrogen and FSH levels like in group 1 anovulatory infertility?

A

Oestrogen low

FSH low or normal

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13
Q

What are oestrogen and FSH levels like in group 2 anovulatory infertility?

A

Oestrogen normal

FSH normal

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14
Q

What are oestrogen and FSH levels like in group 3 anovulatory infertility?

A

Oestrogen low

FSH high

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15
Q

How would you manage someone who has a group 1 ovulation disorder?

A

If BMI < 19 - increase weight

if high levels of exercise - moderate exercise

treatment - gonadotrophin for ovulation induction

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16
Q

What is the female athlete triad that impacts fertility?

A

Low energy availability/eating disorders

Low bone mass

menstrual disturbance

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17
Q

What is the most common cause of group 2 anovulatory infertility?

A

PCOS

18
Q

What is the triad of PCOS symptoms called? What are they?

A

Rotterdam criteria - need 2 of:

Polycystic ovaries on US
Oligo/anovulation
Clinical/biochemical hyperandrogenism

19
Q

How would you manage anovulation in PCOS?

A

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

20
Q

What are the diagnostic criteria for group 3 ovulation disorders (Premature ovarian insufficiency)?

A

Oligo/amenorrhoea for at least 4 months

Elevated FSH level >25
on 2 occasions
> 4 weeks apart.

Patient <40yrs

21
Q

What are some causes of premature ovarian insufficiency?

A 
Turner syndrome
Chromosomal material
Fragile X
Anti-adrenal antibodies
Thyroid peroxidase antibodies
22
Q

How would you manage group 3 (premature ovarian insufficiency) ovulation disorders?

A

Fertility treatment

Oocyte donation

HRT (prevent osteoporosis)

(no interventions to increase ovarian activity and natural conception rates)

23
Q

What are some causes of pelvic pathology that could inhibit reproduction?

A

PID
Endometriosis
Past abdo/pelvic infection or surgery

24
Q

How could you investigate pelvic causes for reduced fertility?

A

hysterosalpingography (low risk women)

hysterosalpingo-contrast-ultrasonogrpahy

GOLD STANDARD: LAPAROSCOPY

25
Q

What should a male sperm count be? What is it called if this is not the case?

A

> =15 million/ml

Oligozoospermia

26
Q

What should the progressive motility of male sperm be? What is it called if this is not the case?

A

> =32%

Asthenozoospermia

27
Q

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?

A

4%

Teratozoospermia

28
Q

What are some causes of male infertility?

A

Idiopathic (most common)

Hypogonadism (medically treatable)

Genetic causes

Testicular trauma/surgery/developmental abnormalities

Obstructive (vasectomy/infection)

Anabolic steroids (not always reversible)

Previous chemotherapy

29
Q

How is male infertility managed?

A

If there is sperm in the ejaculate: ICSI

If there isn’t sperm in the ejaculate: surgical sperm retrieval or donor sperm

30
Q

How should unexplained infertility be managed?

A

Exclude all causes
Recommend 2 years of trying
IVF

(ovulation induction and intrauterine insemination are not of benefit)

31
Q

When can IUI be used?

A

difficulty with sexual intervourse: physical disability
psychosexual issues

donor sperm

32
Q

What is the process of IVF?

A

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

33
Q

What is ovarian hyper stimulation syndrome (OHSS)?

A

Too much hormone given = some serious symptoms for women. Can be life-threatening.

34
Q

What are some symptoms of mild OHSS?

A

Abdo bloating
Mild abdo pain
Ovarian size <8cm

35
Q

What are some symptoms of moderate OHSS?

A

Abdo pain
nausea and vomiting
USS of ascites
Ovarian size 8-12

36
Q

What are some symptoms of severe OHSS?

A 
Clinical ascites
oliguria
hyponatraemia
hyperkalaemia
hypo-osmolality
hypoprotinaemia
ovarian size >12 cm
37
Q

What are some symptoms of critical OHSS?

A

Tense ascites
Haematocrit >0.55
WCC >25000
Oliguria/anuria

38
Q

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?

A

Ovarian hyperstimulation

Ultrasound pelvis and abdomen
Bloods

39
Q

What advice can be given to men about fertility preservation? When should these be done

A

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

40
Q

What advice can be given to women about fertility preservation? When should these be done

A

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

41
Q

What are the risks of egg donation? How does age impact egg donation?

A

Hypertensive disorders of pregnancy
Pre-term birth
Low birth weight

Pregnancy > 40: increased maternal and foetal risks

GOSH (33 decks)

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