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GYNAECOLOGY > Sub/Infertility > Flashcards

Sub/Infertility Flashcards

1
Q

Define infertility

A

Failure to conceive despite regular unprotected intercourse

NICE - doesn’t specify
WHO - 1 yr

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2
Q

After how long should fertility be investigated for a couple trying to conceive?

In what special cases should investigations be done earlier?

A

1 yr

If the female is >35 yrs old 
Amenorrhoea 
Oligomenorrhoea
Past PID 
Undescended testes 
Cancer treatments
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3
Q

Female Causes:

At what age does fertility steeply decline?

A

Late 30s

Also known as premature ovarian failure, happens when a woman’s ovaries stop working normally before she is 40.

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4
Q

Ovulatory causes:

1) HPO failure (hypogonadotropic hypogonadal)
- Psych disease leading to this
- Kallmann’s syndrome - what is it?

2) Normogonadotrophic normoestrogenic causes:
- PCOS is the main cause of this. How does this happen?

A

Anorexia + intense exercise

Congenital low GnRH and anosmia

Unclear mechanism, but there is evidence of arrested antral follicle development, which, in turn, may be caused by abnormal interaction of insulin and luteinizing hormone (LH) on granulosa cells.

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5
Q

Ovulatory causes:

3) Primary ovarian failure (hypergonadotropic hypoestrogenic):
- What type of menopause may happen?
- What type of cancer Rx could cause this? - 2
- What genetic disease could lead to this? - 2
- Another metabolic disease that causes infertility with not know the cause?

4) Hyperprolactinaemia - why does this inhibit GnRH release? What can cause this?

A

Premature menopause

Radiotherapy
Chemotherapy

Turners
Fragile X

Raised prolactin levels suppress oestrogen release, therefore, causing irregular or no ovulation.

Prolactin-secreting pituitary tumour.

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6
Q

Tubular Causes:

The most common cause?

What can cause adhesions? - 4

A

PID

Endometriosis
Appendicitis
IBD
Abdo surgery

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7
Q

Other uterine causes:

What submucosal tumour could lead to infertility?

What is ashermans syndrome?

A

Fibroids

An acquired uterine condition that occurs when scar tissue (adhesions) form inside the uterus and/or the cervix.

It is characterized by variable scarring inside the uterine cavity, where in many cases the front and back walls of the uterus stick to one another.

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8
Q

What might be wrong in the cervix which doesn’t allow sperm to cross?

A

Thick, dry, or sticky mucus is often caused by hormonal imbalances and frequently co-occurs with ovulation problems.

A thickened consistency directly interferes with sperm motility.

Some medication side effects can cause this.

Acidic mucus creates an environment hostile to sperm.

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9
Q

Male causes:

The most common unexplained reason?

Drugs:

  • Why does alcohol affect sperm?
  • Why do anabolic steroids affect sperm?

Genetic:
- Why are men with CF infertile?

A

Low sperm count which can’t be explained

Lowering testosterone levels, FSH, and LH, and raising oestrogen levels, which reduce sperm production. shrinking the testes, which can cause impotence or infertility. changing gonadotropin release which impacts sperm production.

Most men with CF (97-98 percent) are infertile because of a blockage or absence of the sperm canal, known as the congenital bilateral absence of the vas deferens (CBAVD).

The sperm never make it into the semen, making it impossible for them to reach and fertilize an egg through intercourse.

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10
Q

Male causes:

Infection:

  • Mumps - why does this cause infertility?
  • Chlamydia - why does this cause infertility?
A

When the disease gets bad, inflammation doesn’t confine itself to one gland. Inflammation of the pancreas can also happen.

And, for the post-pubescent, the virus can go for the endocrine glands – the mammary glands and the ovaries in women, and the testes in men.

Women can be rendered infertile by severe inflammation, but it’s rare.

Men who develop orchitis, inflammation of the testicles, are slightly more likely to be rendered infertile.

This does not happen to the majority of men infected with mumps, but it can happen.

Many men who get the mumps experience some negative fertility effects.

Dramatic genetic damage in sperm leading to male infertility

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11
Q

Male causes:

Anatomical:

  • Varicocele - what is it?
  • Why are undescended testes bad?
  • Retrograde ejaculation - what is it?
A

An enlargement of the veins within the loose bag of skin that holds your testicles (scrotum).

A varicocele is similar to a varicose vein you might see in your leg.

Causes a lower sperm count and quality
—–
When semen enters the bladder instead of emerging through the penis during orgasm.

Although you still reach sexual climax, you might ejaculate very little or no semen.

This is sometimes called a dry orgasm. Retrograde ejaculation isn’t harmful, but it can cause male infertility.

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12
Q

Male causes:

Trauma and surgery:

  • Why can inguinal hernia repair lead to this?
  • What surgery is used to prevent sperm reaching semen?

What should you make sure you ask about that may be embarrassing?

A

Due to injury to the vas deferens

Vasectomy

Erectile dysfunction

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13
Q

History:

What should you ask the woman?

What should you ask the man?

What should you ask in regards to sex and relationships?

A

Gynae Hx

Groin surgery
Mumps
Alcohol
ED

Frequency
Timing
Mood
Technique

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14
Q

Examination:

What should be measured?

Why are swabs taken?

What is used to measure size of testes?

A

BMI

Chlamydia

Prader Orchidometer

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15
Q

MALE - Investigations:

Oligospermia:

  • What is it?
  • What can cause it?

Azoospermia:

  • What is it?
  • Non-obstructive cause?
  • Obstructive causes?

Asthenozoospermia:
- What is it?

A

Not enough sperm

No sperm prod.

Chromosomal causes

Reduced sperm motility

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16
Q

MALE - Investigations:

Semen analysis - what is key to remember?

How long after should the sperm analysis be repeated if abnormal?

Endocrine:

  • What does raised FSH suggest?
  • What are LH and Testosterone used to find?

Chromosomal and genetic testing for what

A

It is still normal for > 90% of sperm to be abnormal

Testicular failure
Androgen deficiency

Excluding CF and other genetic diseases

17
Q

FEMALE - Investigations:

It is important to establish whether she is ovulating. What signs would indicate she is ovulating?

Formal testing:

  • Mid-luteal progesterone is measured. How many days before their period is it measured? What does raised P suggest? What if their cycle is irregular?
  • FSH - what suggests ovarian failure?
  • LH/FSH - what does this being raised suggest?
A

If cycles are regular and she has midcycle symptoms (fever, abdo pain)

7 days before period
Indicates ovulation
P is checked every 2-3 days

Raised FSH

PCOS
Menopause

18
Q

FEMALE - Investigations:

Further endocrine testing:

  • What hormone is measured for PCOS?
  • Why is prolactin measured?

TVUS:

  • What indicates PCOS?
  • What indicates endometriosis?
  • What indicates fibroids?
  • What indicates uterine polyps?
A

Testosterone

Polycystic ovaries

Lesions and adhesions on pelvic structures

Masses around uterus

Can see on scan - may also be causing IMB, PCB or PMB

19
Q

FEMALE - Investigations:

Further tests for tubal disease:

  • How is chlamydia investigated?
  • What type of imaging can be used to look for tubular disease? - 2
A

Vaginal swab + PCR

Hysterosalpingogram contrast XR (HSG) or laparoscopy + dye (gold standard but invasive)

20
Q

Management - Primary Care:

Advise for any couple concerned about fertility:

  • How often should they be having sex?
  • What should they stop doing - lifestyle?
  • Under what BMI should they get to? What does a lower BMI also increase the chances of success in?
  • What should be prescribed before pregnancy?
  • What virus should be tested for and provided immunisation for due to its adverse effects on a foetus?
  • What should be checked to make sure it ts up to date?
A

Sex every 2-3 days

Stop smoking

BMI < 30

Increases chances of IVF success
Also helps sperm count

Folic acid

Rubella virus

Smears

21
Q

Management - Primary Care:

After 1 yr of trying, offer formal assessment, starting with what:

  • What should be tested in both sexes?

Indications for an earlier referral?

A

Bloods to check for ovulation in women.
Semen analysis in men.

Features of an underlying cause of infertility:

  • Dysmenorrhoea
  • Pani
  • PMH of gynae problems

Female >35 yrs and trying for 6 months

22
Q

Management - Secondary Care - FEMALE:

What lifestyle change should be done?

What medication is used to stimulate ovulation as the first line?

What laparoscopic surgery is done for patients with PCOS?

What drug can be given to induce ovulation which is only prescribed by a specialist fertility unit?

Tubal disease:

  • What fertility Rx can be done that won’t involve ovulation near the ovaries?
  • What can be done for endometriosis?
A

Weight loss/gain

Clomifene citrate

Laparoscopic ovarian drilling

IVF

Resect or ablate any endometriosis

23
Q

Management - Secondary Care - MALE:

What multivitamins can be prescribed?

What is ICSI which is the main tool for most male infertility? Why is it used?

What can be done for obstructive azoospermia?

A

Vit C
Zinc
Selenium

Intracytoplasmic sperm injection - Sperm injected directly into the egg

Surgical correction of epididymal blockage - 1st line
Sperm retrieval from testes/epididymis - 2nd line

24
Q

Unexplained fertility:

How is this defined?

Options for this:

  • IVF - what does it stand for?
  • IUI - what does it stand for?

IUI - this is a good alternative for people who can’t have sex. Give some examples of this?

A

Unable to conceive after 2 yrs of trying, despite normal investigations

In-vitro fertilisation

Intrauterine insemination 
-----
Disabled 
ED 
Same-sex couples
25
Q

Clomifene:

MOA?

Indications?

Why are only 6-12 rounds allowed?

Why do they need follicular monitoring?

Side effects - read?

A

Oestrogen receptor modulator - induces ovulation

Anovulation due to PCOS

Risk of ovarian cancer

Risk of hyperstimulation

Flushes 
Visual 
Abdo pain 
Increased risk of multiple pregnancies 
Ovarian cancer
26
Q

Laparoscopic ovarian drilling:

What type of patient is this done in?

How is it done?

What hormone does it reduce, restoring feedback mechanisms?

A

PCOS patients

Small holes are drilled into each ovary using needlepoint diathermy

Reduces LH

27
Q

In Vitro Fertilisation:

NHS criteria:

  • Under what age and why?
  • Under what BMI should the women be?
  • What else should the couple not have?

Complications:

Ovarian hyperstimulation syndrome:

  • What is it?
  • Symptoms
  • How long after hCG injection does it happen?
  • How is it managed?
A 
<42 yrs - very low success rate
BMI<30 
No kids including stepchildren 
----
The ovaries swell and become painful due to artificial ovulatory stimulation

Abdo pain/distention
N&V

A few days after

Supportive care - analgesia etc.

GYNAECOLOGY (35 decks)

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