reproductive medicine Flashcards
what are the 3 main factors which influence fertility
healthy sperm
healthy fallopian tube
healthy menstrual cycle - ovulation + endometrium
how common is sub-fertility?
1 in 6 women
what are the different causes of infertility
anovulatory infertility - 30% malefactor - 35% tubal disease - 25% endometriosis - 5% unexplained 15%
what are some pre-conception advise for women who want to get pregnant
stop smoking
no alcohol intake
BMI < 19 and > 30 can impact the fertility
age
occupational hazards
recreational drugs
what are some pre-conception advise for men who want to get pregnant
stop smoking BMI > 30 will impact fertility 3-4 units of alcohol per week loose-fitting underwear inc scrotal temp - dec fertility
occupational hazards
recreational drugs
what vitamin should be given pre-conceptions?
folic acid - 0.4mg/day
- 5mg/day
vitamin D - 10mcg/day
in what situation will you give 5mg of folic acid per day?
if previous children/personal/FH of neural tube defect
if DM T1/2
If BMI > 30
coeliac disease
if carrier/suffer of haemoglobinopathies eg thalassemia tract
antifolate drugs
when will you consider a referral to reproductive medicine
when the couple has been trying for at least 1 year with sexual intercourse every 2-3 days or other reasons eg
- female age > 35 know fertility problem - anovulatory cycles - severe endometriosis - previous PID - malignancy
what are some anovulatory disease that can cause infertility
Brain
- hypothalamic hypogondaism (due to anorexia, stress, exercise)
- hyperprolactinaemia (pituitary damage or tumour)
thyroid
- hypo/hyperthyroidism
adrenal hyperplasia
ovaries
- PCOS, premature ovarian insufficiency
what can be an indication of prolactinoma
visual field defect
what are some of the management of subfertility
1 - clomifene - encourage ovulation
2 - gonodatrophin - used when FSH is normal and clomifene resistance PCOS
3 - laproscopic ovarian diathermy - destroy part of the ovary to release an egg
4 - insulin sensitizer - used in PCOS/weight loss more effectie
5 - surgery - treat any adhesion, tubal damage, assisted pregnancy
what is the WHO classification of anovulatory infertility
3 different groups
Group 1 - hypothalamic pituitary failure - brain
Group 2 - hypothalamic-pituitary-ovarian dysfunction (PCOS)
Group 3 - ovarian failure (premature ovarian insufficiency)
what is a primary ovarian failure
the patient was never able to conceive ever
what is a secondary ovarian failure
the patient previously conceived but not able anymore
what are some causes to primary ovarian failure
premature ovarian failure genetic turner's syndrome autoimmune iatrogenic - surgery/chemo
what are some causes to secondary ovarian failure
PCOS
excessive weight loss or exercise
hypopituitarism - tumour, surgery, trauma
hyperprolactinaemia
what is the effect of prolactin in the body
acts on the breast for lactation
what is the effect of prolactin in the hypothalamus
prolactin causes -ve feedback on the thalamus
what are the diagnostic criteria of premature ovarian failure
oligo/amenorrhoea for >4 m
elevated FSH > 25 IU/L > 4 wks apart
what is the mean menopausal age in the UK?
51
what age is considered to be pre-term menopause
<40
what age is considered to be premature menopause
40-45
how common is POI
1% of women < 40
what is the classical hormonal pictures of POI
oestrogen and inhibin are both low
FSH is elevated
what is the main P/C of POI?
amenorrhoea/oligomenorrhoea
difficulty conceiving
menopausal symptoms
what are the managements of POI?
as there are only a few ovum left and so oocyte donation is the only viable way to get pregnancy
not other proven ways to increase the responsiveness of the oocytes
what is nidation
it is the process which the cilia is wafting the ovum/embryo down to the endometrium
what are some causes to tubal damages?
infection - chlamydia
endometriosis
surgery - adhesion
what are some examples of surgical damages that can cause tubal damages?
TOP - adhesion and retention of the conception material
what can be done to improve the chance of pregnancy in women who have endometriosis
surgery to remove extra-endometrial material
what are some investigations that can be done to check for tubal patency
hysterosalpingogram - radioactive dye injected into the endometrium and X-ray taken to see patency
Hysterosalpingo-contrast-ultrasonography - alternative to HSG and no radiation since USS
laparoscopy with dye - gold standard, can diagnose pathology and treatment
what are the risk/SE of HSG and Hysterosalpingo-contrast-ultrasonography
can be uncomfortable
can cause spasm of the fallopian tube - false +ve
but general good specificity and sensitivity
what is the risk of laparoscopy with dye in detecting tubal defect
general anaesthesia risks and surgical risks
what are included in the semen analysis
volume total sperm count concentration of sperm vitality progressive motility total motility normal morphology
what are some causes to male factor infertility
idiopathic (most common) genetic hypogonadism testies trauma/surgery/developmental abnor obstructive anabolic induced previous chemo/radio
what is the treatment for male factor infertility if sperm present in the ejaculation
ICSI
what is the treatment for male factor infertility if sperm absent in the ejaculation
sperm donor or surgical retrieval of sperm
what is ART
assisted reproductive technolgies
what does ART include
any fertility treatments in which sperm and oocytes are handled with the aim for pregnancy
IVF, ICSI, IUI, PGD, egg donation and surrogacy
what does IUI stand for?
Intra-uterine injection
what does IVF stand for?
in-vitro fertilisation
what does ICSI stand for?
Intra-cytoplasmic sperm injection
what does PGD stand for?
pre-implantation genetic diagnosis
what is the best mode of ART for male factor infertility
ICSI
what is the best mode of ART for tubal damage
IVF
what are the indications of IVF
tubal damage endometriosis anovulation male factor subfertility reduced fertility with inc maternal age
what are depending factors of successful IVF
duration of subfertility age elevated FSH previous pregnancy previous failed IVF presence of hydrosalpinx and intramural fibroids smoking and inc BMI
what is the procedure of IVF
1) FSH given to stimulate he releases of eggss
2) HCG given to help mature egss
3) needle guide aspiration
4) sperm collected and place in the same ditch as eggs for fertilisation - Day 0
5) Day 1 - check to see if fertilisation has taken place or not
6) leave to mature further until Day 5
7) selected embryo is re-inserted back into the endometrium + luteal support by progesterone
8) pregnancy test 2 weeks after
how many embryos are given in a single circle of IVF
max 2
what do you do with the already fertilised embryo
can freeze them for later
what is the difference between IVF and ICSI
IVF simply place the sperms near egss
ICSI insert sperms directly into eggs
what single test should be performed before ICSI being carried out?
karyotype for CF
what is IUI
intra-uterine insemination - placing sperms inside the womb of women
when is IUI considered
usually lesbian couple
what are some side effect of ART
egg collection - intra-peritoneal haemorrhage and pelvic infection
pregnancy complications - inc multiple pregnancies, rate of ectopic pregnancy are also higher
genetic - chromosomal and gene abnor associated with inc risk in ICSI
mental wellbeing
superovulation - multiple pregnancies and ovarian hyper-stimulation
what is ovarian hyperstimulation syndrome
complications of ovulation induction or superovulation leading to vEGF over-expression
what are some of the symptoms of ovarian hyperstimulation syndrome
abdo pain bloating N+V inc ovarian sizes ascites
what is the classical picture of OHSS
inc ovarian size
fluid shift from intra to extracellular compartment to abdo and pleural spaces
intravascular fluid depletion - hypercoagulopathy, haemoconcentration
RF for OHSS
PCOS
low BMI
previous OHSS
management of OHSS
symptomatic relief
prevention of haemoconcentration and thromboembolism
maintenance of cardiorespiratory function
paracentesis for ascite
consider heparin for thrombophylaxis
