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SamerZ > Subfertility > Flashcards

Subfertility Flashcards

1
Q

What is a natural cycle IVF?

A

It is an IVF procedure in which one or more oocytes or collected from ovaries during spontaneous menstrual cycle without the use of drugs

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2
Q

Definition of mild male factor infertility

A

It is when two samples of semen analysis have at least one variable that is below the fifth percentile

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3
Q

What are the indication for early referral to an infertility specialist?

A

Women’s age: more than 36 years
If that is a known clinical cause of infertility or a history of predisposing factors for infertility

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4
Q

When should investigation be performed for a patient undergoing artificial insemination?

A

If she fails to conceive within six cycles of treatment

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5
Q

When is male sub fertility is considered severe?

A

If on two different occasions we have one severely abnormal value or 2 mild abnormalities

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6
Q

When is investigated needed when dealing with subfertility?

A

Investigation is needed after one year of unprotected sexual intercourse and patients below 36 years of age or if 6 cycles of artificial insemination were not successful or if the patient is higher risk, meaning she’s above 36 years of age (then we investigate after 6 months) or if she has cancer and needs intervention then investigation and evaluation should be performed as early as possible

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7
Q

After investigating a risk couple after one year of unprotected sexual intercourse with no pregnancy. If the investigation turned out negative, what would be the next step?

A

In this situation, expected management for another year is warranted then investigations are repeated if they are still normal then IVF is indicated

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8
Q

For high risk patients after 6 months of unprotected sexual intercourse with no pregnancy, investigation is indicated. How should we proceed if the investigations turned out to be normal?

A

A 6-months expectant management should be performed followed by another set of investigation, if the investigation are still normal then IVF is needed

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9
Q

What is the chance for a woman under 40 years of age to conceive using IUI after 6 cycles and after 12 cycles?

A

50%
75%

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10
Q

What is the chance of couples in the general population to conceive within one year or 2 years if the woman is aged less than 40 years and they have regular sexual intercourse?

A

80%
90%

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11
Q

What is the effect of smoking on male and female fertility?

A

Both male and female fertility can be decreased due to smoking even if passive
Semen quality was reduced among smokers

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12
Q

What is the advice to give for couples who are trying to conceive regarding alcohol intake?

A

Woman are allowed to consume 1 to 2 units of alcohol per week
Men are advice to consume less than three to four per day

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13
Q

When should we investigate a woman with signs of PCOS and 2 month history of infertility?

A

Immediately.
Every time we have a calls for infertility investigation should not be delayed. It respective of the time to get pregnant.

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14
Q

Relationship between caffeine intake and infertility

A

No consistent data linking fertility to caffeine intake

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15
Q

Male infertility and tied underwear

A

Tight underwears are associated with increased scrotal temperature and reduce semen quality

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16
Q

Relationship between BMI and infertility

A

For patients with BMI more than 30 and not ovulating, losing weight is likely to increase the chances of conception
Men with BMI more than 30 are likely to have reduced fertility
For women with a BMI of less than 19 and irregular or no menstruation, increasing their body weight is likely to improve their chance of conception

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17
Q

What are the terminology used to describe a semen analysis?

A
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18
Q

What is the recommended dose of folic acid to take before pregnancy and for how long?

A

For low risk patients it is recommended to take a dose of 0.4 mg per day for 12 weeks before gestation and for 12 weeks after
The patients that are considered high risk are the ones with a BMI more than 30, diabetes mellitus, thalassemia, sickle cell disease, history of neural tube defect (maternal or paternal) Celiac disease sulfasalazine intake
These high risk patients are required to take 5 mg per day
And the ones with structured problems are required to take folic acid throughout pregnancy, not just for 12 weeks

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19
Q

What are the semen analysis parameters as per the WHO?

A

Cement volume more than 1.5
pH more than 7.2
Total sperm count more than 39 millions per ejaculation
Sperm concentration more than 15 million per ml
Total motility more than 40% progressive motility more than 32%
Normal morphology more than 4%

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20
Q

Which of the following investigations is it required to predict outcome of fertility treatment?

A

Ovarian volume
Ovarian blood flow
Inhibin B
Estradiol E2

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21
Q

How can AFC predict low and high response?

A

If less than 4: low response
If more than 16: response

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22
Q

How can AMH predict IVF treatment response?

A

AMH less than 5.4 low response
AMH more than 25 high response

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23
Q

How can FSH predict IVF treatment response?

A

FSH more than 8.9: low response
FSH less than 4: high response

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24
Q

What is the first test to do in the investigation of infertility?

A

Simen analysis
If mildly normal repeat in 3 months
If severely abnormal: Repeat as soon as possible

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25
Q

What investigations to be done if there is suspicion of tubal and uterine abnormalities?

A

Hysterosalpingogram

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26
Q

What other investigations to be performed when female infertility is suspected?

A

Other than the HSG
Prolactin measurement if a woman has ovulatory disorder galactorrhea or a pituitary tumor
Thyroid function test if symptoms of thyroid
Endometrial biopsy SHOULD NOT be offered to check for luteal phase defect

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27
Q

What is the best confirmatory test for ovulation?

A

Serum progesterone in mid luteal phase
If the patient has regular cycles then this is done at day 21
If the patient has irregular cycles this should start at day 21 and keep repeating every 7 days till we have menstruation
For this irregular cycle woman, we can also offer FSH and LH

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28
Q

What is the best modality to assess tubal status in case of PID ectopic pregnancy and endometriosis?

A

In this situation we don’t do HSG we go directly for laparoscopy

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29
Q

Should we offer viral screening for a male going for infertility treatment?

A

Yes, we should offer HIV hepatitis B and hepatitis C

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30
Q

Should we offer sperm washing for patients that are HIV positive?

A

If the patient is on HAART treatment with a viral load less than 50 for more than 6 months and no other associated infections then washing is not needed
Washing will reduce but will not eliminate transmission risk
Do not offer washing for men with hepatitis B

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31
Q

If a male is HIV positive with viral load less than 50 for more than 6 months and no other infections, the female should not be taking prep to avoid infection

A

True

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32
Q

Should we offer surgical correction of obstructive azoospermia?

A

Yes

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33
Q

Should we offer varicocelectomy for male and fertility with varicocele?

A

If short-term history: no
If long term history: Yes, you may offer

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34
Q

Male factor fertility treatment:
1-Hypogonadotropic hypogonadism
2-Idiopathic semen abnormalities
3-Leukocyte and semen
4-Anti-sperm antibody

A

For Hypogonadotropic hypogonadism: offer gonadotropins
For idiopathic semen abnormalities: anti-estrogens gonadotropins androgens bromocritin or kinin-enhancing drugs (not effective
For leukocyte in semen: do not offer antibiotic
For anti sperm antibody: might benefit from systemic corticosteroid

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35
Q

Should we screen for any STD before uterine instrumentation??

A

Yes, we should screen for chlamydia trachomatis
If no screening was performed, consider the prophylactic antibiotic before urterine instrumentation

36
Q

In WHO group II ovulation disorders, what is the first line treatment?

A

If BMI more than 30 lose weight
Offer clomid
Or clomid and metformin

37
Q

Treatment for WHO Group I ovulation disorder:

A

Increase body weight if BMI less than 19
Advice to decrease level of exercise
And to induce ovulation offer pulsatile administration of gonadotropins with or without LH activity

38
Q

What is the first line ovarian simulation agent used?

A

Clomid with or without metformin depending on the BMI

39
Q

What is the maximum period of treatment with clomid?
What is clomid resistance versus clomid failure?

A

The maximum treatment Is 6 months
Clomid resistant: when a woman fails to ovulate despite increasing doses of clomid (proof of ovulation is seeing on ultrasound a follicle between 18 and 20 mm in size)
Clomid failure if the patient was able to ovulate on clomid but was not able to get pregnant after six cycles

40
Q

Scheme to treat PCOS infertility
PCOS failure

A
41
Q

Scheme to treat PCOS infertility
PCOS resistant

A
42
Q

How do we manage clomid failure?

A

IVF

43
Q

How do we manage clomid resistance?

A

1- metformin
2- GnRH if Obese
3- ovarian drilling if thin

44
Q

WHO clasification of ovulation disorders

A
45
Q

In case of hydrosalpinx, is salpingectomy indicated?

A

Yes

46
Q

How to treat infertility causing amenorrhea and intrauterine adhesions?

A

Offer hysteroscopic adhesiolysis

47
Q

Is tubal microsurgery indicated for the treatment of tubal factor and fertility?

A

When the problem is proximal it can be done. It improves pregnancy rate

48
Q

Should we treat hyperprolactinemia for infertility?

A

Yes, treat with bromocriptine if amenorrhea exists

49
Q

In the case of unexplained infertility with mild endometriosis or mild male factor infertility and regular unprotected sexual intercourse
should we offer IUI?

A

No, IUI is not indicated in the situation
Try conception for a total of 2 years then IVF

50
Q

What are the factors that can influence IVF treatment??

A

More than one unit of alcohol consumption per day
Maternal and paternal smoking
Maternal caffeine intake

51
Q

What are the most important predictors of IVF success?

A

The most important factor is female age
Previous pregnancy history
BMI between 19 and 30

52
Q

How many embryos to transfer according to age during an IVF procedure?

A
53
Q

Is ultrasound guided embryo transfer recommended?

A

Yes
Improves pregnancy rates

54
Q

Bed rest for more than 20 minutes. Duration following embryo transfer: is this a recommended step to do?

A

No, it does not improve pregnancy rate

55
Q

Went to consider donor insemination?

A
56
Q

ICSI versus IVF

A

ICSI improves fertilization rate but pregnancy rate is the same

57
Q

ICSI indication:

A
58
Q

In case of donor insemination should the patient be induced?

A

If the patient is ovulating, offer a minimum of six cycles of donor insemination without ovarian stimulation

59
Q

In case of donor insemination, should we offer tubal assessment first?

A

Tubing assessment can be done after three cycles of donor insemination

60
Q
A
61
Q
A
62
Q

Sperms parameters

A
63
Q

What are the investigation to do in case of unexplained infertility?

A
64
Q

Infertility with intrauterine septum?

A

Hystoryroscopic septoplasty

65
Q

Fibroid and infertility

A

If subserosal : conservative management
Submucosal: myomectomy
Intramural: myomectomy firnfibroids more than 50mm distorting the cavity

66
Q

Polyp and infertility?

A

Polypectomy

67
Q

Superficial endometriosis and infertility?

A

Laparoscopy

68
Q

Deep endometriosis and infertility?

A

Laparoscopy for symptoms relief

69
Q

Endometrioma and infertility?

A

Remove if endometrioma more then 40 mm

70
Q

Recurrent endometriosis and infertility?

A

Laparoscopy for symptoms relief

71
Q

Does ART increase the risk of malignancy??

A

No increase in the risk except for borderline ovarian tumors

72
Q

Overview of factors affecting treatment outcome in ART

A
73
Q

Factors affecting outcomes in ART

A
74
Q

Factors affecting male fertility(1)

A
75
Q

Factors affecting male fertility(2)

A
76
Q

Factors affecting male fertility(3)

A
77
Q

What are the risk factors for OHSS?

A

History of OHSS
Polycystic ovarian syndrome
High AFC
High AMH
Send lean patient

78
Q

Can OHSS be managed as an outpatient?

A

Yes when it is mild or moderate
Paracentesis can also be performed as an outside basis for symptomatic relief

79
Q

What are the investigations to do for OHSS?

A

CBC
CRP
Electrolytes and urea
Liver function test
Serum osmolality
Coagulation profile
HCG
Ultrasound scan (check ovarian size and abdominal free fluid)

80
Q

OHSS classification?

A

Mild: ovarian size less than 8 cm3 mild symptoms
Moderate ovarian size between 8 and 12 cm 3
Ultrasound evidence of ascites, nausea and vomiting
Severe OHSS clinical asitis, ovarian size more than 12 cm 3, All the signs of hemo concentration
Critical OHSS: tense asitis, hydrothorax, severe hemoc concentration hematocrite more than 0.55, ARDS

81
Q

Management tips in OHSS?

A

Only mild and moderate cases to be treated as outpatient
Avoid anti-inflammatory drugs
Don’t use gnrh antagonist
For mild cases treated at home, they should get evaluated every two to three days in the clinic. Having respiratory symptoms is an indication for paracentesis
LMWH usually indicated until first trimester if the patient became pregnant or until discharge if not pregnant
OHSS is a medically managed pathology

82
Q

What is the most common complication following an ART procedure for a singleton pregnancy?

A

Preterm labor 11% for a single pregnancy

83
Q

What is the most common complication following an ART procedure for an extremely advanced maternal age?

A

C-section. 79%

84
Q

What is the most common complication following an ART procedure in case of an egg donor?

A

Severe pre-eclampsia

85
Q

What is the most common complication following an ART procedure in case of twins?

A

C-section

SamerZ (3 decks)

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