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Subfertility Flashcards

1
Q

Define infertility.

A

Failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sex.

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2
Q

What is the difference between primary and secondary infertility?

A

Primary - being unable to conceive at all

Secondary - losing the ability to conceive (i.e. already having a successful pregnancy)

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3
Q

What % of cases of infertility are unexplained?

A

25%

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4
Q

Describe the different ovulatory causes of infertility.

A

Type 1: hypopituitary failure (commonly caused by anorexia nervosa)
Type 2: hypopituitary dysfunction (e.g. PCOS, hyperprolactinaemia)
Type 3: ovulatory failure (menopause, premature if <40 y/o)

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5
Q

What is PCOS?

A

PolyCystic Ovarian Syndrome - means having 10+ follicles per ovary on US scan

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6
Q

What symptoms/signs according to the Rotterdam criteria must be met in order to have a diagnosis of PCOS?

A

2 out of 3 of:

  • clinical hyperandrogenaemia
  • oligomenorrhea (<6-9 periods/yr)
  • polycystic ovaries in US
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7
Q

What physical symptoms can PCOS cause?

A 
Menstrual disturbance 
Infertility 
Hirsutism
Acne
Male-pattern hair loss
Central obesity 
Acanthosis nigricans
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8
Q

What clinical conditions must be excluded before making a diagnosis of PCOS?

A

Thyroid dysfunction
Congenital adrenal hyperplasia
Hyperprolactinaemia
Androgen-secreting tumour

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9
Q

Describe the different tubal and uterine causes of infertility.

A
  1. PID (can cause tubal scarring)
  2. Previous tubal surgery (inc. for ectopic pregnancy) = tubal scarring
  3. Endometriosis (tubal and uterine effects)
  4. Fibroids
  5. Cervical mucus defect (mucus can be ‘hostile’ to sperm)
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10
Q

What % of women develop tubal infertility after:
A. 1 episode of PID
B. 3 episodes of PID

A

a. 10%

b. 50%

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11
Q

What are some of the symptoms of acute PID?

A 
Plevic pain
Deep dyspareunia 
Malaise
Fever 
Purulent vaginal discharge
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12
Q

What investigations are carried out to diagnose PID? What are the treatment options?

A

Investigations:
Endocervical swab (ECS) - microscopy, culture and sensitivity
STI test (especially for chlamydia)
FBC

Treatment:
Antibiotics
Rest
Abstinence

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13
Q

What is endometriosis?

A

Presence of tissue histologically similar to endometrium outside the uterine cavity and myometrium

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14
Q

How many women are affected by endometriosis? What are the risk factors?

A

1 in 5 affected

Risk factors: increased risk with age , FH, frequent cycles

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15
Q

What treatment options are there for endometriosis?

A 
Combined oral contraceptive pill (COCP)
Pregnany protect
NSAIDs for pain
Norethisterone 
Danazol 
GnRH agonist
Surgery
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16
Q

What is another name for fibroids? What are they?

A

Uterine leiomyoma

Benign tumours of the SMOOTH MUSCLE of the myometrium

17
Q

What are the different types of fibroids?

A

Named by location:

  • subserosal
  • pedunculated
  • intramural
  • submucosal
18
Q

What treatment options are there for fibroids?

A

Tranexamic acid, COCP/LARCs, surgery

19
Q

Describe the different male causes of infertility.

A

Testicular (infection, cancer, surgical, congenital, undescended + trauma)
Azoospermia with or without sperm antibodies
Reversal of vasectomy
Ejaculatory problems (retrograde and premature)
Hypogonadism

(diabetes and depression can causes erectile dysfunction)

20
Q

What drugs have been linked to female/male/both causes of infertility?

A

Women: Long-term NSAIDs use, chemotherapy, neuroleptics, spironolactone, depo-provera

Men: Sulfasalazine, anabolic steroids, chemotherapy, chinese herbs

Both: marijuana, cocaine + other ilicit drugs

21
Q

How long must a couple be trying to conceive for before getting a referral? In what cases are earlier referrals made?

A

2 years (as 90% of couples conceive within 2 years)
Earlier referrals if:
- woman >/= 36 years
- known cause of infertility.hisotry of predisposing factors of infertility

22
Q

What investigations are carried out by a GP before referral to a fertility clinic is made?

A

Full sexual/contraceptive/fertility history
FBCs (fibroids or iron deficiency anaemia)
PCOS screen (Day 21 progesterone, LH, FSH, serum testosterone, glucose)
TFTs/TSH
Vitamin D
HbA1c
Viral screen (rubella, HIV, hepatitis screen)
STI screen and smear check
Maybe semen analysis

23
Q

What are the normal values for sperm count in terms of volume, progressive motility, morphology?

A

volume: 1.5 mL
progressive motility: 32%
morphology: 4%

24
Q

What kind of tests are carried out in secondary care to investigate ovulatory function, tubal function and uterine function?

A

ovulatory function = bloods, ovarian reserve testing (how would they respond to Gn stimulation)
tubal function = hystersalpinogram
uterine function = laparoscopy

25
Q

What advice/treatment would be given to a female with hypopituitary failure?

A

increase weight, reduced excessive exercise

pulsatile GnrH or Gn with LH activity to induce ovulation

26
Q

What advice/treatment would be given to a female with PCOS?

A

Make sure BMI is =30
Clomiphene (non-steroidal SERM) for 6 months MAX
Metformin
Combined clomiphene + metformin
laparoscopic ovarian drilling and Gn therapy

27
Q

What advice/treatment would be given to a female with hyperprolactinaemia?

A

Bromocriptine (not safe in pregnancy)

28
Q

What advice/treatment would be given to a female with ovarian failure?

A

Donor eggs/alternative parenting strategies

29
Q

What advice/treatment would be given to a female with tubal/uterine infertility?

A

laparoscopic tubal surgery
surgery prior to IVF attempt for fibroids/endometriosis
adhesiolysis

30
Q

What advice/treatment would be given for male infertility causes?

A

NOT MANY TREATMENTS :((
treat infections, surgery for testicular causes
gonadotrophins for hypogonadism
diabetes and depression support

31
Q

What does ICSI stand for?

A

Intracytoplasmic sperm injection

32
Q

What is the success rate for intrauterine insemination/IVF for women:

a. <35
b. >44

A

intrauterine insemination:

a. 15.8%
b. 0%

IVF:

a. 32.2%
b. 1.9%

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