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MFSRH part 2 > Subfertility > Flashcards

Subfertility Flashcards

1
Q

Causes of pre-testicular male subfertility

A

Hypothalamic disease

  • Kallmans
  • Prader-Willi
  • CHARGE

Pituitary pathology

  • Tumours
  • Brain injury including iatragenic
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2
Q

Testicular causes of male subfertility

A

Genetic

  • Kleinfelters
  • Noonan’s

Cryptorchidism

Acquired

  • injury
  • varicocele
  • tumours
  • chemo / radiotherapy
  • idiopathic
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3
Q

Post testicular causes of male subfertility

A

Congenital

  • Congenital absence of the vas deferens
  • CF
  • Youngs

Acquired

  • Infection
  • Vasectomy

Sperm dysmotility

  • Immotile cilia syndrome
  • Maturation defects
  • Immunological infertility
  • Globozoospermia

Sexual dysfunction

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4
Q

For a couple with unexplained subfertility what is the likelihood they will conceive with expectant management?

A

In unexplained subfertility chances of conceiving with expectant management are high

74% of couples conceive within 12 months

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5
Q

What is WHO Group I ovulation disorder

A

Ovulation Disorders

WHO Group I : Hypothalamic pituitary failure
Stress, anorexia, exercise induced

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6
Q

What is WHO Group II ovulation disorder

A

ovulation disorder

WHO Group II :
Hypothalamic-pituitary-ovarian dysfunction
PCOS

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7
Q

What is WHO Group III ovulation disorder

A

ovulation disorder

WHO Group III : Ovarian failure

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8
Q

What type of ovulation disorders sit outside of the WHO classification?

A

Hyperprolactinaemic amenorrhoea/anovulation (sits outside WHO classification)

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9
Q

Management of WHO Group I ovulation disorders (Hypothalamic pituitary failure e.g. Stress, anorexia, exercise induced)

A

Increase BMI if <19 kg/m2
Reduce exercise if high levels
Pulsatile GnRH or Gonadotrophins with LH activity to induce ovulation

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10
Q

Management of WHO Group II ovulation disorders

Hypothalamic-pituitary-ovarian dysfunction e.g PCOS

A 
Weight reduction if BMI >30
Clomifene/ Clomiphene (1st line)
Meformin (1st line)
Combined clomiphene &amp;  Metformin (1st/2nd line)
Laparoscopic drilling (2nd line)
Gonadotrophins (2nd line)
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11
Q

Management of WHO Group III ovulation disorders

Ovarian failure

A

Management Group III

Consider IVF with donor eggs

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12
Q

Management of Hyperprolactinaemia related ovulation disorders?

A

Management of Hyperprolactinaemia induced ovulation disorder

Investigate cause e.g. MRI head (?pituitary adenoma) 
medication review (some antipsychotic medications can cause prolactin rise)

Dopamine agonist (Bromocriptine advised by NICE as 1st line)

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13
Q

What percentage of men with cystic fibrosis have subfertility?

A

98%

Typically due to failure of the vas deferens to develop properly

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14
Q

Normal semen volume

A

Semen volume: 1.5 ml +

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15
Q

Normal semen PH

A

pH: 7.2 +

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16
Q

Normal semen concentration per ml

A

Sperm concentration:
Greater than or equal to
15 million spermatozoa per ml

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17
Q

Normal total sperm count per ejaculate

A

Total sperm number: 39 million spermatozoa per ejaculate

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18
Q

Normal total sperm motility

A

total motility: 40% or more

progressive motility: 32% or more

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19
Q

Normal sperm vitality on semen analysis

A

Vitality: 58% or more live spermatozoa

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20
Q

Semen analysis % normal morphology

A

Sperm morphology (percentage of normal forms):

4% or more

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21
Q

Management of abnormal semen analysis

A

repeat sample in 3 months (unless severe azoospermia)

If abnormalities persist
then do hormone profiling (look for hypogonadotrophic hypogonadism which may be treatable with gonadotrophins)

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22
Q

What percentage of couples with subfertility have unexplained subfertility

A

30-40%

of subfertile couples have unexplained subfertility

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23
Q

Serious adrenal or ovarian pathology is suggested by a Female testosterone level greater than what

A

Testosterone levels greater than

5 nmol/L (or 1.5ng/ml)

point towards serious ovarian or adrenal pathology

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24
Q

Psychological effects of subfertility

A 
Can affect both partners 
stress 
relationship impact 
reduce libido
Financial concerns and pressures 
Uncertainty 
Anxiety 
Low mood
Grief 
Anger
Denial
Loss of self esteem or self worth
Guilt 
Feeling of a lack of control 
Altered sleep
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25
Q

Management of psychological consequences and contributors of sub-fertility

A

Inform re fertility support group
offer counselling
Relaxation techniques
Medication if diagnosed mental health condition and benefits outweigh risks to potential pregnancy

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26
Q

For people using artificial insemination to conceive what is the usual conception rate?

A

using artificial insemination to conceive for F <40
> 50% women conceive within 6 cycles IUI

A further half will conceive with a further 6 cycles

cumulative pregnancy rate ~ 75%

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27
Q

Advice re alcohol for couples trying to become pregnant

A

Women should drink no more than 1 - 2 units of alcohol once or twice per week and avoid episodes of intoxication

Men should should not exceed 1-2 units per day to avoid affecting semen quality / sperm count

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28
Q

Advice re smoking for couples trying to become pregnant

A

Women who smoke should be informed this is likely to reduce their fertility

offer referral to a smoking cessation programme

Passive smoking is likely to affect chance of conception

Men who smoke have a risk of reduced semen quality. Stopping smoking will improve general health.

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29
Q

Features of ovarian hyperstimulation syndrome

A 
Abdo pain
Ascites 
Hypovolaemic shock 
Pleural effusion 
Thrombosis 
Retail failure 
Death
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30
Q

What is maximum ovum survival believed to be?

A

24 hours

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31
Q

What is maximum sperm survival believed to be?

A

7 days

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32
Q

Where are spermatozoa produced and where do the become motile?

A

Produced in seminiferous tubules and become motile il the epididymis

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33
Q

Where is inhibin produced

A

Sertoli cells

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34
Q

What does a secondary spermatocyte divide into

A

2 spermatids

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35
Q

What does a primary spermatocyte divide into

A

2 secondary spermatocytes

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36
Q

What are primary spermatocytes formed from

A

Spermatogonium

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37
Q

Does smoking cigarettes affect female fertility?

A

Yes.

There is a direct correlation between the number smoked and the incidence of female infertility

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38
Q

Main causes of infertility in the UK

A 
Factors causing male infertility (30%)
Ovulatory disorders (25%)
Tubal damage (20%)
Uterine or peritoneal disorders (10%)
No cause identified (25%)
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39
Q

Advice re caffeine for a couple trying for pregnancy

A

No consistent evidence of an association between caffeine and fertility problems

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40
Q

Advice re high BMI for a couple trying for pregnancy

A
  • Women with a BMI of 30+ are likely to take longer to conceive
  • Women with a BMI 30+ and not ovulating will increase chance of conception by losing weight.
  • Participating in a group programme involving exercise + dietary advice leads to more pregnancies than weight loss advice alone.
  • Men with a BMI 30+ are likely to have reduced fertility
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41
Q

Advice re low BMI for a couple trying for pregnancy

A

Women with a BMI <19 and have irregular menstruation / amenorrhoea - increasing body weight likely to improve chance of conception

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42
Q

Advice re tight underwear for a couple trying for pregnancy

A

Men - association between elevated scrotal temperature and reduced semen quality.
Uncertain if loose-fitting underwear improves fertility

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43
Q

When should a referral to fertility services be made before 12m of attempting conception?

A

Earlier referral for specialist consultation where:

  • woman aged 36 years or over
  • Known clinical cause of infertility or history of predisposing factors
  • if treatment is planned that may result in infertility (such cancer tx)
44
Q

investigatory steps for a couple with fertility difficulties

A 
semen analysis
Menstrual cycle regularity
F FSH level and progesterone
F prolactin level - if ovulation disorder or galactorhoea 
STI screen 
Hysterosalpingography if no risk factors for tubal disease, otherwise lap and dye
Rubella susceptibility test
recent cervical smear
HIV, Hep B and C if having IVF
45
Q

Is screening for anti-sperm antibodies recommended for investigating subfertility?

A

No, no evidence of effective treatment

46
Q

management if initial semen test is abnormal

A

repeat semen test 3m later
Allows for complete spermatozoa cycle to be completed
Offer repeat earlier if severe oligozoospermia / azoospermia

47
Q

What is the first line measure of female ovarian reserve?

A

age

48
Q

Are ovarian volume and ovarian blood flow markers of fertility

A

No

Not reccommended

49
Q

Are onhibin B and

oestradiol (E2) levels recommended for subfertility investigation

A

No

50
Q

Timing of a progesterone blood test for fertility investigation?

A

Mid-luteal phase

Day 21 of a 28‑day cycle

To confirm ovulation

51
Q

Timing of a progesterone blood test for fertility investigation if F has irregular / absent cycle

A

random

or calculate from timing of prev cycles and repeat weekly until next cycle starts

52
Q

For a sero-discordant HIV couple with a +ve M, the transmission is low from UPSI if what 4 conditions are met

A
  1. Compliant with ARVs
  2. Plasma VL undetectable for 6m+
  3. no other infections present
  4. UPSI limited to time of ovulation
53
Q

when should sperm washing be offered

A

If serodiscordant couple where +ve male partner is non compliant with ARVs or VL is not <50 or has notbeen <50 for >6m

54
Q

What effect does sperm washing have on the risk of HIV transmission to the F

A

Reduces it

but does not eliminate the risk

55
Q

why are women offered rubella susceptibilty testing at fertility clinics

A

to enable offer of vaccination if susceptible

56
Q

Why is an STI test recommended for investigation of fertility patients

A

to exclude infection before undertaking uterine instrumatation / HSG which could promote PID / spread

57
Q

Management of men with leucocytes in semen analysis

A

None

Treat with antibiotics only if symptoms of infection

58
Q

Management of known antisperm antibodies

A

Explain the significance of antisperm antibodies is unclear

The effectiveness of systemic corticosteroids is uncertain

59
Q

Management of men with obstructive azoospermia

A

Offer surgical correction of epididymal blockage - likely to restore patency and improve fertility.

Or surgical sperm recovery and IVF

60
Q

Management of varicoceles in a couple with subfertility

A

Men do not offer surgery for varicoceles for fertility treatment
- does not improve pregnancy rates.

61
Q

Monitoring ovulation induction during gonadotrophin therapy for fertility patients

A

ovulation induction with gonadotrophins = risk of multiple pregnancy and ovarian hyperstimulation

Ovarian ultrasound monitoring - measure follicular size and number

62
Q

risks of ovulation induction with gonadotrophins

A

risk of multiple pregnancy and ovarian hyperstimulation

63
Q

Management of fertility patient with mild tubal disease

A

tubal surgery may be more effective than no treatment.

Or tubal catheterisation / hysteroscopic cannulation

64
Q

Management of fertility patient with hydrosalpinges

A

offer salpingectomy
preferably laparoscopically
before IVF
improves chance of live birth

65
Q

Management of fertility patient with intrauterine adhesions

A

hysteroscopic adhesiolysis

66
Q

management of unexplained infertility

A

DO NOT offer ovarian stimulation agents
Regular UPSI for 2 years
then consider IVF

67
Q

when is intrauterine insemination considered as a treatment option for fertility

A

People who are unable to, or find it very difficult to, have vaginal intercourse because of a clinically diagnosed physical disability or psychosexual problem

Conditions requiring specific consideration in relation to method of conception (e.g. after sperm washing)

Same sex relationships.

68
Q

management of people recommended to try IUD and who do not conceive after 6 cycles of insemination.

A

Confirm evidence of normal ovulation, tubal patency and semenalysis.

Offer further 6 cycles of unstimulated IUI before IVF considered

69
Q

factors predicting IVF success

A 
Female age
Number of previous treatment cycles
previous pregnancy history
BMI
alcohol intake
smoking
caffeine consumption
70
Q

How does previous pregnancy history influence IVF outcome

A

IVF treatment is more effective in women who have previously been pregnant and/or had a live birth

71
Q

Recommended BMI for IVF treatment to increase chance of success

A

Aim for 19-30.
Ideally 19-25 is preferable.
BMI >30 will reduce success rates

72
Q

what is the NICE recommended IVF treatment for women under 40

A

<40yo
Not conceived after 2 yr regular UPSI or 12 cycles of IUI
offer 3 full cycles of IVF
With or without ICSI

If F reaches age 40 during treatment complete current full cycle but do not offer further full cycles

73
Q

what is the NICE recommended IVF treatment for women age 40-42

A

F aged 40–42
Not conceived after 2 years regular UPSI or 12 cycles IUI

offer 1 full cycle of IVF
With or without ICSI,

provided 3 criteria are met:

  1. never previously had IVF
  2. No evidence of low ovarian reserve
  3. Discussion of additional implications of IVF / pregnancy at this age
74
Q

Pre-treatment for IVF

A

Pre-treatment with oral contraceptive pill or progestogen) as part of IVF does not affect the chances of having a live birth.

Consider pre-treatment in order to schedule IVF treatment for women who are not undergoing long down-regulation protocols

75
Q

Down regulation protocols in IVF

A

Down regulation / other regimens used to avoid premature LH surges in IVF

Use GnRH agonist down-regulation or GnRH antagonists

Only offer GnRH -agonists to F with low risk of OHSS

When using GnRH -agonists use a long down regulation protocol

76
Q

How is controlled ovarian stimulation in IVF achieved

A

Ovarian stimulation as part of IVF
Use urinary or recombinant gonadotrophins.

Individualised starting dose of FSH 
Based on factors that predict success
- age
- BMI
- presence of polycystic ovaries
- ovarian reserve
DO NOT use >450 IU/day of FSH
77
Q

How is ovulation triggered in IVF

A

Offer women human chorionic gonadotrophin to trigger ovulation in IVF treatment.
+ ultrasound monitoring of ovarian response

78
Q

Management of a patient undergoing oocyte retrieval in IVF

A

TV retrieval of oocytes - offer conscious sedation

79
Q

When should follicle flushing be offered when retrieving oocytes for IVF

A

If less than 3 follicles have developed

80
Q

Management of embryo transfer stages in IVF

A
  • Ultrasound-guided embryo transfer improves pregnancy rates.
  • Only place embryos into a uterine cavity with an endometrium of 5 mm +
  • Bed rest of more than 20 minutes’ duration following embryo transfer does not improve the outcome of IVF treatment
  • Evaluate embryo quality, at both cleavage and blastocyst stages
81
Q

NICE recommendations for number of embroyos to be transfered during IVF aged <37yo

A

For women <37 yrs:

  • 1st full cycle - transfer 1 embryo
  • 2nd full cycle use 1 top quality embryo or 2 lower quality embyos
  • in 3rd cycle offer 2 embryo transfer
82
Q

NICE recommendations for number of embryos to be transferred during IVF aged 37-39yo

A

For women 37-39 yrs:

  • 1st and 2nd cycles - transfer 1 top quality embryo or 2 lower quality
  • 3rd cycle offer 2 embryo transfer
83
Q

NICE recommendations for number of embryos to be transferred during IVF aged 40+

A

For women 40yrs +:

- Consider 2 embryo transfer for all cycles

84
Q

NICE recommendations for number of embryos to be transferred during IVF using donor eggs

A

Transfer strategy is based on the age of the donor

85
Q

Luteal phase support after IVF

A

Offer progesterone for luteal phase support after IVF treatment.
Do not routinely offer HcG for luteal phase support = increased likelihood of OHSS

Evidence does not support continuing any form of treatment for luteal phase support beyond 8 weeks’

86
Q

NICE guidance on Gamete intrafallopian transfer and zygote intrafallopian transfer

A

Insufficient evidence to recommend the use of gamete intrafallopian transfer or zygote intrafallopian transfer in preference to IVF

87
Q

Indications for intracytoplasmic sperm injection

A
  • severe deficits in semen quality
  • obstructive azoospermia
  • non-obstructive azoospermia.

And considered for couples where previous IVF resulted in failed / v. poor fertilisation

88
Q

Advice for patients re Intracytoplasmic sperm injection versus IVF

A

ICSI improves fertilisation rates compared to IVF alone

But once fertilisation is achieved the pregnancy rate is no better than with IVF

89
Q

Indications for donor insemination for fertility treatment

A

Effective in managing fertility problems associated with:

  • obstructive azoospermia
  • non-obstructive azoospermia
  • severe deficits in semen quality in couples who do not wish to undergo ICSI

Consider if:

  • high risk of transmitting a genetic disorder
  • high risk of transmitting infectious disease
  • severe rhesus isoimmunisation.
90
Q

Indications for oocyte donation

A

Effective in managing fertility problems associated with:

  • premature ovarian failure
  • gonadal dysgenesis including Turner syndrome
  • bilateral oophorectomy
  • ovarian failure following chemotherapy or radiotherapy
  • certain cases of IVF treatment failure

Considered in certain cases of high risk of transmitting a genetic disorder

91
Q

What is the most common cause of spontaneous miscarriage and implantation failure in those undergoing IVF?

A

Aneuploidies

92
Q

Azoospermia and normal FSH is consistent with what diagnoses? (3)

A

Obstructive cause

  • congenital absence of the vas
  • varicocele
  • tubal blockage secondary to infection, trauma, surgery
93
Q

Azoospermia and raised FSH is consistent with what diagnosis

A

Testicular failure

94
Q

What signs of symptoms would merit admission for OHSS?

6

A 
Tachypnoea / SOB
Hypotension
Tense ascites 
Oliguria
Electrolyte imbalance 
Intractable vomiting
95
Q

Classification of OHSS (1-5)

A 
Mild = grade 1-2
1 = abdo distension and discomfort
2 = 1 + N+V, +/- diarrhoea + ovarian enlargement 5-12cm

Moderate = grade 3 = 2 + uss evidence of ascites

Severe = grade 4-5
4 = 3 + clinical ascites +/- hydrothorax +/- breathing difficulty 
5 = 4+ increased blood viscosity, hypovolaemia, increased coagulation, decreased renal perfusion
96
Q

Long term risks of premature ovarian insufficiency

A 
Infertility 
CVD
Reduced BMD
Increased risk of osteoporosis 
Increased risk of Alzheimer's
Decreased cognitive function  
Decreased verbal fluency 
Impaired memory
97
Q

Diagnosis of POI

A

Age <40
Persistently elevated FSH >30 on 2 tests min 4 weeks apart
Altered menstrual cycle
Menopausal symptoms

98
Q

What autoimmune causes of POI may occur (7)

A 
Addisons
Pernicious anaemia
Hashimotos
Idiopathic thrombocytopenic purpura 
Rheumatoid arthritis with vitiligo
Cushings
Myasthenia gravis
99
Q

Timing for a mid-luteal progesterone sample

A

Day 21

100
Q

Indication for a mid-luteal progesterone sample

A

Irregular menstrual cycle

Or fertility issues to confirm ovulation

101
Q

What level for a mid-luteal progesterone sample is normal for an ovulating woman?

A

> 30 confirms ovulation

102
Q

Effects of metformin used in treatment of PCOS

A 
Decrease insulin secretion (not effective for weight loss)
Increased conception rate 
Improved insulin sensitivity 
Deceased androgen levels 
Decreased hepatic gluconeogenesis
103
Q

Roe of FSH in men

A

Stimulates formation of sperm in the testes

104
Q

How many days does the process of spermatogenesis take?

A

70 - 80 days

105
Q

Impact of sulfasalazine on semen analysis

A

Decrease sperm count
Decrease sperm motility
Increase abnormal forms

Reversible after drug cessation

MFSRH part 2 (24 decks)

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