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OBGYN 4MB > Subfertility > Flashcards

Subfertility Flashcards

1
Q

Define subfertility

A

Failure to conceive after one year of regular unprotected intercourse

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2
Q

What is the incidence of subfertility?

A

15%

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3
Q

What aspects should you ask about in the history of the male partner?

A

HxPC:

  1. Length of time trying
  2. Any symptoms of erectile dysfunction
  3. Ix or Tx so far
  4. Any child from previous relationship

PMed/Surg:

  1. Undescended testes
  2. Mumps orchitis
  3. Cancer

Sexual Hx:
1. Previous STIs

Social Hx:

  1. Occupation
  2. Alcohol
  3. Drug use
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4
Q

What aspects should you ask about in the history of the female partner?

A

HxPC:

  1. How long trying
  2. What Ix and Tx so far
  3. Menarche, periods - duration, cycle, menstrual diary
  4. Are they timing intercourse around ovulation

PMed Hx:

  1. Chronic conditions
  2. Thyroid
  3. DM

P Gynae Hx:

  1. STIs
  2. PID
  3. PCOS
  4. Gynae conditions

P Obs Hx:
1. Past pregnancies if any

Medications:

  1. Folic acid
  2. Other meds

Social Hx:

  1. Smoking
  2. Alcohol
  3. Drug use
  4. Occupation
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5
Q

What would you look for on examination in the male partner?

A
  1. General medical examination
  2. Height - Klinefelter’s syndrome (taller)
  3. Inguinal scars
  4. Size/site of testes
  5. Varicocoele/epididymal cyst
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6
Q

What would you look for on examination in the female partner?

A
  1. General:
    - exophthalmos
    - anaemia
    - goitre
    - hirsutism
    - BMI
  2. Pelvic examination:
    - Masses
    - Cx smear
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7
Q

List the causes of subfertility

A
  1. Anovulation
  2. Male factor
  3. No fertilisation
  4. Unexplained
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8
Q

List the causes of anovulation

A
  1. PCOS
  2. Hypogonadism
  3. Hyperprolactinaemia
  4. Thyroid dysfunction
  5. Ovarian failure

*30% of subfertility

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9
Q

List the causes of male factor subfertility

A
  1. Idiopathic
  2. Varicocoele
  3. Antibodies
  4. Drugs/chemical exposure

*25% of subfertility

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10
Q

List the causes of no fertilisation

A
  1. Tubal damage:
    - Infection
    - Surgery
    - Endometriosis
  2. Cervical <5%
  3. Sexual factor 5%
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11
Q

What percentage of subfertility is unexplained?

A

30%

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12
Q

What investigations would you do for subfertility in the female?

A

BLOODS:

  1. D21 progesterone >30nmol/L (to confirm ovulation) (taken 7days before the subsequent menstruation so may not be D21 depending on length of cycle, mid luteal phase)
  2. D3 FSH/LH
  3. Testosterone, prolactin, TFTs
  4. Rubella status
  5. Anti-mullerian hormone (test of ovarian reserve, not 1st line)

USS:

  • PCO
  • Can monitor follicular growth (generally not done)

LH hormone based urine predictor kits:
- OTC (indicate if LH surge has taken place)

TUBAL PATENCY:

  • Laparoscopy and dye
  • Hysterosalpingogram (less invasive, do this first)
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13
Q

What investigations would you do for subfertility in the male?

A

Semen analysis

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14
Q

List the WHO criteria for semen analysis

A
  1. Volume >1.5mls
  2. Sperm count >15 million/ml
  3. Progressive motility >32%
  4. Morphology >4% normal
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15
Q

How do we do semen analysis?

A
  • Specimen needs to be produced by masturbation and not into a condom
  • Done after 2-5 days of abstinence
  • Specimen needs to be kept at body temperature, and bought to the lab within 1hr from production
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16
Q

What do we do if semen analysis is abnormal?

A
  • Can repeat 3mths after initial analysis (allows time for cycle of spermatozoa formation to complete)
  • If gross spermatozoal deficiency test should be repeat ASAP
17
Q

List the causes of abnormal semen analysis?

A
  1. Unknown
  2. Smoking/alcohol/drugs
  3. Varicocele
  4. Antisperm antibodies
  5. Klinefelter’s syndrome
  6. CF mutation carrier
18
Q

What are the general treatment options for subfertility?

A
  1. Weight loss
  2. Lifestyle advice
  3. Folic acid
19
Q

How is tubal factor subfertility treated?

A
  1. Laparoscopic surgery if mild/endometriosis

2. IVF if fails or severe

20
Q

What is the treatment for anovulation?

A
  1. Clomiphene
    - Selective oestrogen receptor modulator (SERM). Causes release of GnRH by the hypothalamus
    - SEs = Twins 10%, blurred vision, OHSS
  2. Metformin
  3. Gonadotrophins
21
Q

What is the surgical treatment of PCOS?

A

Ovarian diathermy

22
Q

How can we treat male factor infertility?

A
  1. IUI
  2. IVF with or without ICSI
  3. DI
23
Q

What to we use in cases of unexplained subfertility?

A
  1. IUI

2. IVF

24
Q

What are the criteria for diagnosis of PCOS?

A

At least 2 of following 3 criteria must be met:

  1. Polycystic ovaries on ultrasound
  2. Irregular periods (>35days apart)
  3. Hirsutism - clinical (acne or excess body hair) and/or biochemical (raised serum testosterone)
25
Q

List the clinical features of PCOS

A
  1. PCO
  2. Obese
  3. Acne
  4. Hirsutism
  5. Oligomenorrhea or amenorrhea
  6. Miscarriage more common
26
Q

List the complications of PCOS

A
  1. T2DM
  2. GDM
  3. Endometrial cancer
27
Q

How can we treat the other symptoms of PCOS besides infertility?

A
  1. Advice regarding diet and exercise
  2. COCP will normalise menstruation if fertility not required
  3. Anti-androgens (cyproterone acetate or spironolactone) effective for hirsutism but conception must be avoided
  4. Eflornithine - topical anti-androgen for facial hirsutism
28
Q

What are the key points about Clomifene?

A
  1. Traditional 1st line ovulation drug in PCOS
  2. Limited to 6mths use (as anti-oestrogen)
  3. Only given at start of cycle - initiates follicular maturation
  4. Monitored by TVUS
  5. If no follicles develop dose increased in subsequent cycles
  6. If 3 or more follicles develop, cycle cancellation initiated to decrease risk of multiple pregnancy
29
Q

What are the key points about metformin?

A
  1. Insulin sensitising drug used to restore ovulation
  2. Does not promote ovulation so no increase in multiple pregnancy
  3. Taken every day throughout cycle in multiple doses
  4. GI SEs common
  5. Treats hirsutism
30
Q

What are the key points about laparoscopic ovarian diathermy?

A
  1. Second line tx
  2. As effective as gonadotrophins
  3. Lower multiple pregnancy rate
  4. Each ovary monopolar diathermised at a few points for a few seconds
  5. Tubal patency tested during same operation
31
Q

What are the key points about gonadotrophin induction of ovulation?

A
  1. Used when first line treatments have failed
  2. Also given in hypothalamic hypogonadism when weight is normal
  3. Usually maturation of more than one follicle
  4. In PCOS low dose step-up regimen
  5. Follicular developments monitored via US
  6. Follicle of adequate size for ovulation - artificial stimulation of ovulation by injection of hCG or recombinant LH
32
Q

List the side effects of ovulation induction

A
  1. Multiple pregnancy
  2. Ovarian hyperstimulation syndrome (OHSS)
  3. Ovarian and breast carcinoma
33
Q

Define ovarian hyperstimulation syndrome (OHSS)

A

Overstimulation of the follicles in the ovaries and they get very large and painful. More common during IVF than standard ovulation induction

34
Q

List the risk factors for OHSS

A
  1. Gonadotrophin stimulation
  2. Age <35yrs
  3. Previous OHSS
  4. Ovaries of polycystic morphology on US
35
Q

How can we prevent OHSS?

A
  1. Use lowest effective dose of gonadotrophin doses
  2. US monitoring of follicular growth - if excessive withdrawal of gonadotrophins for a few days or cancellation of IVF cycle (withholding hCG injection)
36
Q

What happens in severe cases of OHSS?

A
  1. Hypovolaemia
  2. Electrolyte disturbances
  3. Ascites
  4. Thromboembolism
  5. Pulmonary embolism
  • CAN BE FATAL

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