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O&G > Subfertility > Flashcards

Subfertility Flashcards

1
Q

Tanner scale: Definition

A

The Tanner scale (also known as the Tanner stages) is a scale of physical development in children, adolescents and adults. The scale defines physical measurements of development based on external primary and secondary sex characteristics, such as the size of the breasts, genitals, testicular volume and development of pubic hair.

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2
Q

Subfertility: Important questions to ask

A
  1. Ovulation - ovulating? if annovulation, why?
  2. Ovarian reserve - good, satisfactory, poor, diminised
  3. Tube and transport - Is there a problem with the tubes?
  4. Sperm - present in ejaculate?
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3
Q

Investigations for subfertility: Female with regular cycle (4)

A
  • FSH
  • LH
  • Oestradiol
  • Progesterone
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4
Q

Investigations for subfertility: Female with irregular cycle or amenorrhoea (5)

A
  • FSH
  • LH
  • Estrogen
  • Prolactin
  • Testosterone
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5
Q

Investigations for subfertility: All females (4)

A
  • Rubella serology
  • AMH
  • Cervical smear
  • TVUS
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6
Q

Investigations for subfertility: All males

A
  • Semen analysis
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7
Q

FACTORS that influence a couple’s ability to conceive

A
  • Female age- extremely important with a significant reduction as women age
  • Uterine function- endometrial problems, fibroid, polyps
  • Duration of trying- couples who have a short duration of infertility are more likely to conceive both with or without treatment
  • Lifestyle factors- e.g. obesity, excessive alcohol intake and smoking
  • Medical history– you should also ensure that a patient’s medical condition is optimised for pregnancy e.g. good diabetic control. An infertility consultation is an important time for pre-conception counselling
  • Previous pregnancy
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8
Q

Characteristics of SPERM (4)

A
  • Volume
  • Count
  • Motility
  • Morphology
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9
Q

SEMEN analysis

A

The results of semen analysis conducted as part of an initial assessment should be compared with the following World Health Organization reference values[2]:

• semen volume: 1.5ml or more
• pH: 7.2or more
• sperm concentration: 15million spermatozoa per ml or more
• total sperm number: 39million spermatozoa per ejaculate or more
• total motility (percentage of progressive motility and non-progressive motility): 40% or more motile or 32% or more with progressive motility
• vitality: 58% or more live spermatozoa
sperm morphology (percentage of normal forms): 4% or more.

If the result of the first semen analysis is abnormal, a repeat confirmatory test should be offered.

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10
Q

FACTORS that IMPROVE fertility (8)

A
  • Female age <30 years
  • Previously conceived
  • <3 years of infertility
  • Unprotected intercourse around ovulation time
  • Female BMI of 20-30
  • Non-smokers
  • Limited alcohol intake
  • No recreational drugs
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11
Q

FACTORS that REDUCES fertility (8)

A
  • Female age >35 years
  • Not previously conceived
  • > 3 years of infertility
  • Intercourse not around ovulation time
  • Female BMI <20 or >30
  • One or both partners smoke
  • Excessive alcohol intake
  • Regular use of recreational drugs
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12
Q

CAUSE of INFERTILITY

A
  • Ovulatory problems (20-30%)
  • Tubal (20-30%)
  • Male factor (25-40%)
  • Unexplained (10-20%)
  • Endometriosis (5-10%)
  • Other problems (e.g. fibroids) (4%)
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13
Q

Pre-conception advice: Overview (9)

A
  • Pre-existing medical conditions
  • Weight
  • Smoking
  • Recreational drugs
  • Alcohol
  • Intercourse
  • Folic acid
  • Cervical smear
  • Rubella
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14
Q

Pre-conception advice: PRE-EXISTING MEDICAL conditions

A

The infertility clinic also acts as an important opportunity to ensure that any underlying medical conditions are managed optimally in preparation for pregnancy e.g. optimisation of diabetic control.

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15
Q

Pre-conception advice: WEIGHT

A

BMI should be 19-30 to optimise chance of a successful pregnancy.

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16
Q

Pre-conception advice: SMOKING

A

Very detrimental effect in men and women - therefore STOP.

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17
Q

Pre-conception advice: RECREATIONAL drugs

A

Very detrimental effect in men and women - therefore STOP.

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18
Q

Pre-conception advice: ALCOHOL

A

Evidence of detrimental effect with excessive alcohol intake.

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19
Q

Pre-conception advice: INTERCOURSE

A

Advise intercourse at least every 2 days from approx. 6 days prior to presumed day of ovulation until 2 days after.

However no need to restrict intercourse to these times.

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20
Q

Pre-conception advice: FOLIC acid

A

0.4mg daily reduces the risk of neural tube defects (NTDs) - (400 micrograms)

5mg daily for high risk groups - diabetes, epilepsy, previous NTD - (5 miliigrams)

21
Q

Pre-conception advice: CERVICAL smear

A

Advise to keep up to date. No need for additional smears.

22
Q

Pre-conception advice: RUBELLA

A

Ensure that patient has full immunisation hx.

23
Q

Unexplained subfertility: possible causes

A
  1. Subtle abnormalities in oocyte and/or sperm function.
  2. Defective endometrial receptivity
  3. Subclinical endometriosis
  4. Nutritional factors
  5. Undiagnosed or untreated coeliac diease
  6. Immunological factors
  7. Poor ovarian reserve
24
Q

OVULATION + OVARIAN RESERVE: Summary

A
  • Regular cycle = ovulation but does not indicate ovarian reserve
  • Ovarian reserve indicators – AMH, FSH and antral follicle count do not confirm ovulation but estimate remaining reserve
25
Q

Polycystic ovarian syndrome (PCOS): Definition

A

Polycystic ovary syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age.

The aetiology of PCOS is not fully understood. Both hyperinsulinaemia and high levels of luteinizing hormone are seen in PCOS and there appears to be some overlap with the metabolic syndrome.

26
Q

Polycystic ovarian syndrome (PCOS): Features

A
  • subfertility and infertility
  • menstrual disturbances: oligomenorrhea and amenorrhoea
  • hirsutism, acne (due to hyperandrogenism)
  • obesity
  • acanthosis nigricans (due to insulin resistance)
27
Q

Polycystic ovarian syndrome (PCOS): Investigations

A
  • Pelvic ultrasound: multiple cysts on the ovaries
  • FSH, LH: raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis.
  • TSH
  • Prolactin: may be normal or mildly elevated.
  • Testosterone: may be normal or mildly elevated - however, if markedly raised consider other causes
  • Check for impaired glucose tolerance
28
Q

PCOS: Management - GENERAL

A
  • weight reduction if appropriate
  • if a women requires contraception then a combined oral contraceptive (COC) pill may help regulate her cycle and induce a monthly bleed (see below)
29
Q

PCOS: Management - HIRUITISM + ACNE

A
  • a COC pill may be used help manage hirsutism.
  • if doesn’t respond to COC then topical eflornithine may be tried
  • spironolactone, flutamide and finasteride may be used under specialist supervision
30
Q

PCOS: Management - INFERTLITY

A
  • weight reduction if appropriate
  • the management of infertility in patients with PCOS should be supervised by a specialist.
  • There is an ongoing debate as to whether metformin, clomifene or a combination should be used to stimulate ovulation
31
Q

PCOS: Management - OVERVIEW (6)

A
  • Lifestyle modification
  • Improving menstrual regularity
    (weight loss, COCP, Metformin)
  • Controlling symptoms of hyperandrogenism
    (cosmetic, antiandrogens, COCP)
  • Subfertility (weight loss, ovulation induction)
  • Insulin sensitizers (metformin)
  • Psychological issues
32
Q

HIRSUITISM vs. VIRILIZATION

A

HIRSUITISM is the presence of excessive terminal (coarse) hair in androgen-sensitive areas of the female body (upper lip, chin, chest abdomen, arms + thighs) VIRILIZATION is more extensive than hirsuitism.

33
Q

HIRSUITISM causes

A

Polycystic ovarian syndrome is the most common causes of hirsutism. Other causes include:

  • Cushing’s syndrome
  • congenital adrenal hyperplasia
  • androgen therapy
  • obesity: thought to be due to insulin resistance
  • adrenal tumour
  • androgen secreting ovarian tumour
  • drugs: phenytoin, corticosteroids
34
Q

Endometriosis: Definition

A

Endometriosis is the presence of endometrial-like tissue outside the uterine cavity. It is oestrogen dependent, and therefore mostly affects women during their productive years.

If the ectopic endometrial tissue is within the myometrium itself it is called adenomyosis. Around 10% of women of a reproductive age have a degree of endometriosis.

35
Q

Endometriosis: Clinical features

A
  1. Infertility
  2. Pain
    • Cyclic or constant
    • Dysmenorrhoea (severe)
    • Dyspareunia
    • Dysuria
    • Dyschezia and cyclic pararectal bleeding
    • Chronic fatigue
36
Q

Endometriosis: Investigation

A
  • LAPAROSCOPY is the gold-standard investigation
    there is little role for investigation in primary care (e.g. ultrasound)
  • if the symptoms are significant the patient should be referred for a definitive diagnosis
37
Q

Endometriosis: Aetiology

A

The exact aetiology remains unknown.

Retrograde menstruation with adherence, invasion and growth of the tissue = most popular theory. However >90% show menstrual blood in the pelvis at the time of menstruation.

38
Q

Location of ENDOMETRIOSIS

  • Common (pelvis) (5)
  • Rare (4)
A

Common (Pelvis)

  • Pouch of Douglas
  • Uterosacral ligaments
  • Ovarian fossae
  • Bladder
  • Peritoneum

Rare:

  • Lungs
  • Brain
  • Muscles
  • Eye
39
Q

APPEARANCE of endometriosis (3)

A
  • Peritoneal endometriotic lesions
  • Ovarian endometriotic (chocolate) cysts
  • Deep infiltrating endomtriosis
40
Q

Endometriosis: Approach to diagnosis

  • History
  • Examination
  • Investigations
A

History:

  • Menstrual cycle
  • Nature of pain
  • Haematuria/rectal bleeding during menstruation

Examination:

  • Bimanual exam
  • Speculum exam

Investigations:

  • Laparoscopy = gold standard
  • Can also use TVUS
41
Q

Endometriomas: Definition

A

The presence of endometrial tissue in and sometimes on the ovary - it is the most common form of endometriosis.

42
Q

Endometriosis: Treatment

A

Management depends on clinical features

Pain:

  • NSAIDs and/or paracetamol
  • COCP or progestogens e.g. medroxyprogesterone

If analgesia/hormonal treatment does work:

  • GnRH analogues - induce a ‘pseudomenopause’ due to the low oestrogen levels
  • surgery: laparoscopic excisio
  • surgery: laser treatment of endometriotic ovarian cysts
43
Q

Causes of ANOVULATION:

  • Primary ovarian failure
  • Secondary ovarian failure
A

Primary ovarian failure:

  • Premature ovarian failure
  • Genetic (Turner syndrome - 45X0)
  • Autoimmune
  • Iatrogenic (surgery, chemotherapy)

Secondary ovarian failure:

  • PCOS
  • Excessive weight loss/exercise
  • Hypopituitarism (tumour, trauma, surgery)
  • Kallman’s syndrome
  • Hyperprolactinaemia
44
Q

FEMALE subfertility: Management (2)

A
  • Lifestyle modification

- Ovulation induction

45
Q

FEMALE subfertility: Lifestyle modification (7)

A
  • Healthy diet
  • Stop smoking/recreational drugs
  • Reduce alcohol consumption
  • Regular exercise
  • Folic acid
  • Avoid timed intercourse (every 2-3 days)
  • Avoid ovulation induction kits/basal temperature measurements (no evidence of success and stressful)
46
Q

FEMALE subfertility: Ovulation induction (8)

A
  • PCOS: correction of specific problem
  • Weight loss/gain - as appropriate
  • Anti-oestrogens
  • Gonadotrophins or pulsatile GnRH
  • Laparoscopic ovarian diathermy
  • Insulin sensitisers (Metformin)
  • Surgery
  • Assisted reproduction (IUI, IVF, oocyte donation)
47
Q

MALE subfertility: Overview

A

Accounts for 20-25% of cases of subfertile couples. Investigation should start in primary care after 1 yr; or earlier if history of genital surgery, cancer treatment or previous subfertility.

48
Q

MALE subfertility: Investigations (3)

A
  • Semen analysis
  • FSH (elevated in testicular failure)
  • Karyotype (exclude 47XXY)
  • Cystic fibrosis screen: congenital bilateral absence of the vas deferens (CBAVD)
49
Q

MALE subfertility: Management

A
  • Treat any underlying cause
  • Address lifestyle issues
  • Review medications
  • Medical treatments
  • Surgical treatments
  • Sperm retrieval
  • Assisted reproduction
  • Donor sperm
  • Adoption

O&G (13 decks)

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