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Subfertility Flashcards

1
Q

What is subfertility?

A

When conception has not occurred after 1 year of unprotected sexual intercourse

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2
Q

What are the different types of subfertility?

A
  1. Primary: Never conceived

2. Secondary: Has conceived previously

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3
Q

What is oligozoospermia?

A

<15 million/ml sperm

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4
Q

What is asthenozoospermia?

A

A reduction in sperm motility around 30%

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5
Q

What is teratozoospermia?

A

A reduction in sperm morphology around 4%

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6
Q

What is azoospermia?

A

No sperm

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7
Q

What is severe oligospermia?

A

<5 million/ml

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8
Q

In what cases can you refer women to subfertility clinic before 1 year of trying to conceive? (2)

A
  1. If the women is >36 YO

2. Known clinical cause of infertility eg. PCOS

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9
Q

What is the effect of an increased maternal age on fertility? (3)

A
  1. Decreases fertility due to a decrease in ovarian reserve
  2. Increase in miscarriage rates
  3. Increase in foetal chromosomal abnormalities
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10
Q

What is the effect of maternal BMI >30 on fertility? (3)

A
  1. Takes longer to conceive
  2. Increased miscarriage rate
  3. Increased pregnancy complications
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11
Q

What is the effect of maternal BMI <20 on fertility? (3)

A

Annovulation

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12
Q

What is the effect of paternal BMI >30 on fertility?

A

Reduced fertility

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13
Q

What is the effect of maternal smoking on fertility?

A

Reduced fertility

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14
Q

What is the effect of paternal smoking on fertility?

A

Reduced semen quality

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15
Q

What is the effect of paternal alcohol intake on fertility?

A

Reduces semen quality

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16
Q

What is the effect of Maternal alcohol intake on fertility?

A

No effect on fertility - intoxication harms a developing foetus

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17
Q

What important questions do we need to know when assessing a females fertility? (10)

A
  1. Age
  2. LMP + details of menstruation
  3. Any history of dysmenorrhoea
  4. Coital frequency and problems
  5. Previous pregnancy history and problems
  6. Previous PID/surgery
  7. Medical history + meds
  8. FH - DVT + genetic disease
  9. Smoking/alcohol/BMI
  10. Smear test
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18
Q

What important questions do we need to know when assessing a males fertility? (8)

A
  1. Age
  2. Occupation
  3. How many children he has
  4. Social - smoking, drinking, drugs
  5. Previous operations
  6. History of mumps/trauma
  7. Medical conditions + drugs
  8. Coital problems and frequency
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19
Q

List 7 causes of infertility + how common they are

A
  1. Unexplained - 30%
  2. Ovulatory disorders - 3-%
  3. Tubal damage - 25%
  4. Male factors - 25%
  5. Cervical problems - 5%
  6. Coital problems - 5%
  7. Uterine or endometrial problems
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20
Q

What is Clomifene citrate?

A

Ovarian stimulating agent

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21
Q

How is Unexplained infertility managed?

A
  1. Do not offer climifene citrate

2. Offer IVF if women has not conceived after 2 years of regular unprotected sex

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22
Q

What are 3 psychological effects of infertility?

A
  1. Relationship problems
  2. Stress
  3. Loss of libido
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23
Q

How do we apporoach managing psychological effects of infertility?

A
  1. Counselling
  2. Support groups
  3. Specialis teams
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24
Q

Why is it important to take folic acid up to 12 weeks of gestation?

A

Reduces the risk of having a baby with neural tube defects

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25
Q

What is the recommended daily dose of folic acid

A

0.4 mg

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26
Q

In which 2 circumstances should we consider giving 5 mg of folic acid daily?

A
  1. Previous infant with a neural tube defect

2. Mums taking anti-epileptic medication

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27
Q

How often is it recommended to have sexual intercourse to optimise the chance of pregnancy?

A

Every 2-3 days

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28
Q

When should artificial insemination happen?

A

Around ovulation

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29
Q

List 4 non-pathological causes of abnormal semen analysis

A
  1. Unknown
  2. Smoking/alcohol/drugs/chemicals/tight underwear
  3. Genetic
  4. Antisperm antibodies
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30
Q

How do we investigate male infertility?

A
  1. Semen analysis - repeat in 12 weeks if abnormal
  2. Scrotum examination
  3. Bloods- FSH/LH/TST/prolactin and testosterone
  4. Karyotyping
  5. Cystic fibrosis
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31
Q

What are the causes of abnormal/absent sperm release? (5)

A
  1. Idiopathic
  2. Drug exposure - alcohol/smoking/drugs
  3. Exposure to chemicals
  4. Varicocele - 25%
  5. Anti-sperm antibodies
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32
Q

Which 2 medications cause abnormal sperm release?

A
  1. Sulfasalazine

2. Anabolic steroids

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33
Q

In patients with antisemen antibodies, what do you see on semen analysis? (2)

A

Poor motility

clumping

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34
Q

When are men at a high risk of developing antisperm antibodies?

A

After vasectomy reversal

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35
Q

What are the causes of abnormal semen?

A
  1. Infection - mumps, epididymitis
  2. Testiculer abnormalities - Klinefelter syndrome XXY
  3. Obstruction: Cystic fibrosis leading to congenital absence of the Vas
  4. Hypothalamic problems
  5. Kallmans syndrome
  6. Retrograde ejaculation - into bladder
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36
Q

What happens to FSH, LH and testosterone in kallmans syndrome?

A

Reduced

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37
Q

What causes retrograde ejaculation? (2)

A
  1. Diabetes

2. TURP

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38
Q

What happens to FSH, LH and testosterone in primary testicular faliure?

A

High FSH, LH

Low testosterone

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39
Q

What causes primary testicular failure? (3)

A
  1. Cryptorchidism
  2. Surgery
  3. Radiotherapy/chemotherapy
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40
Q

What do you need to test for if a patient presents with azoospermia and absent Vas deferens?

A

Cystic fibrosis work up

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41
Q

What are the 4 classifications for male infertility aetiology?

A
  1. Hypothalamic pituitary disease - secondary hypogonadism 1/2%
  2. Testicular disease - primary hypogonadism 30/40%
  3. Sperm transport problems 10/20%
  4. Unexplained - 40/50%
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42
Q

How is male infertility managed? (oligo/moderate/azoopermia) to assist in conception

A
  1. Optimise lifestyle factors
  2. Oligospermia - intrauterine insemination
  3. Moderate/severe oligospermia: IVF +/- ICSI
  4. Azoospermia: surgical sperm retrieval then IVF +/- ICSI or donor insemination
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43
Q

What lifestyle advice do you give infertile men

A
  1. Loose clothing
  2. No smoking, alcohol, drugs
  3. Loose weight
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44
Q

What does IVF stand for?

A

In vitro fertilization

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45
Q

What does ICSI stand for?

A

Intracytoplasmic injection

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46
Q

What medication can we use to manage male infertility?

A
  1. Hypogonadotrophic hypogonadism - injections of LH/FSH +/- HCG for 6 months
  2. Corticosteroids (unclear)
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47
Q

How is male infertility surgically managed?

A
  1. obstructive azoospermia is offered surgical correction of epididymal blockage - to restore patency of the duct and improve fertility
48
Q

Does varicocele surgery improve fertility?

49
Q

How can we increase fertility in patients with cryptorchidism?

A

Evidence shows that orchidopexy at 9 months improves spermatogenesis compared to at 3 years

50
Q

Disorders of ovulation - WHO classification

A
  1. Group one: Hypothalamic pituitary failure (hypothalamic amenorrhea or hypogonadotrophic hypogonadism)
  2. Group two: Hypothalamic-pituitary-ovarian dysfunction - PCOS
  3. Group three: Ovarian faliure
51
Q

What signs/symptoms are associated with ovulation? (4)

A
  1. Mittlechmerz - pelvic pain and spotting around ovulation
  2. Vervical mucous - preovulation is acellular and forms a fern pattern on a dry slide after ovulation
  3. Spinnbarkeit - elastic like string up to 15 cm pre-ovulation
  4. Rise in temperature by 0.5 degrees
52
Q

What blood test do we use to detect ovulation in a regular cycle?

A

Mid-luteal serum progesterone - day 21 - correct depending on cycle length

53
Q

Which day you you use progesterone levels to test for ovulation in a 35 day cycle?

54
Q

What blood test do we use to detect ovulation in a regular cycle?

55
Q

Other than blood test, what other tests can we use to test for ovulation?

A
  1. US for follicular tracking - not routine
  2. Temperature charts
  3. Urine predictor kits to indicate LH surge - USED
56
Q

What is PCOS?

A

Polycystic ovaries

57
Q

What percentage of women suffer from PCO?

What Percentage of women suffer from PCOS?

58
Q

Describe ovary changes in PCOS? (3)

A
  1. > 12 cyst
  2. Small 2-8 mm follicles
  3. Enlarged ovary > 10 ml
59
Q

What is the Rotterdam consensus criteria for PCOS?

A

The presence of 2/3 of:

  1. PCO either 12+ follicles or ovarian volume >10 cm
  2. Oligo-ovulation or anovulation
  3. Clinical signs: Acne, Hirsutism, excess body hair, testosterone > 5 nmol
60
Q

What causes PCOS? (7)

A
  1. Increased Androgen
    a. Genetic
    b. Raised LH
    c. Increased adrenal androgens
    d. Reduced hepatic production of SHBG which leads to increased free androgen levels.
    c. High BMI
  2. Insulin disturbances
    a. Peripheral insulin resistance
    b. Raised insulin levels
    c. High BMI
61
Q

What are the clinical features of PCOS? (8)

A
  1. Obese
  2. Acne
  3. Hirsuitism
  4. Oligomenorrhea
  5. Amenorrhea
  6. Subfertility
  7. Miscarriage
  8. Family history of diabetes
62
Q

How do we investigate PCOS? (8)

A
  1. Transvaginal scan
  2. FSH –normal
  3. AMH -high
  4. LH-often raised
  5. Testosterone-raised
  6. Screen for diabetes/abnormal lipids/cardiovascular disease
  7. Prolactin (to exclude hyperprolactinemia)
  8. TSH -hyperthyroidism
63
Q

What are the long term complications of PCOS? (3)

A
  1. T2DM
  2. Gestational diabetes
  3. Endometrial cancer
64
Q

How are PCOS symptoms treated? (Other than infertility)

A

Advise regarding diet and exercise

Combined oral pills to regularise the cycles and hirsuitism

At least 3-4 bleeds in a year

Cyproterone acetate and spironolactone for hirsuitism

65
Q

What Drugs are used to induce ovulation in PCOS? and what days is it taken?

A
  1. Clomifene day 2-6

2. Letrozole

66
Q

What drugs are used to treat PCOS?

A
  1. Clomifene
  2. Anti-oestrogen (to increase LH/FSH)
  3. Metformin
  4. Oral aromatase inhibitor - Letrozole
67
Q

What is the effect of Metformin on Clomifene?

A

Increases effectiveness

68
Q

What Surgical treatment is done for PCOS?

A

Laparoscopic ovarian drilling - each ovary is cauterised with monopoler

69
Q

What Causes anovulation in women? (5)

A
  1. PCOS
  2. Hypothalamic hypogonadism
  3. Hyperprolactinaemia
  4. Thyroid disease
  5. Premature ovarian failure
70
Q

What are the hypothalamic causes of Infertility in women? (2)

A
  1. Reduction in GnRH release
    causing reduced FSH and LH
    Seen with anorexia nervosa, athletes/stress
  2. Kallmann’s syndrome- GnRH secreting neurons fails to develop
71
Q

What are the Pituitary causes of Infertility in women? (2)

A
  1. Hyperprolactinemia – excess prolactin reduces GnRH release
  2. Benign tumour (adenoma) or hyperplasia Associated with PCOS/drugs/hypothyroidism
72
Q

What symptoms are associated with Hyperprolactinemia? (3)

A
  1. Galactorrhoea
  2. Amenorrhea
  3. Oligomenorrhea
73
Q

What symptoms are associated with adenomas causing infertility? (2)

A
  1. Headaches

2. Bitemporal hemianopia

74
Q

How do you investigate adenomas causing infertility?

75
Q

How do we treat pituitary causes of infertility?

A
  1. Dopamine agonists- Bromocriptine and cabergoline (dopamine inhibits prolactin release)
  2. Surgery indicated if medical treatment fails
76
Q

What is premature ovarian insufficiency?

A

When estradiol and inhibit levels are reduced at the age of <40 causing a rise in FSH + LH due to the lack of negative feedback.

77
Q

How do we help women with premature ovarian insufficiency conceive?

A

Donor eggs

78
Q

Is AMH high or low in ovarian insufficiency?

79
Q

What are the side effects of induction of ovulation?

A
  1. Multiple pregnancies with clonigene/Gonadotrophin/letrozole
  2. Ovarian and breast cancer
80
Q

What is ovarian hyper stimulation syndrome?

A

Overstimulation of the ovaries by gonadotrophin

81
Q

What signs/symptoms are associated with ovarian hyper stimulation syndrome?

A

Large and painful ovaries

82
Q

What increases the risk of ovarian hyper stimulation syndrome?

83
Q

What are the risk factors of ovarian hyper stimulation syndrome? (4)

A
  1. Gonadotrophin stimulation
  2. age<35
  3. PCO
  4. Previous OHSS
84
Q

How do we prevent Ovarian hyper stimulation syndrome? (3)

A
  1. Use low doses of gonadotrophins
  2. Follicle monitoring
  3. Cancellation of IVF cycle
85
Q

What are the signs/symptoms associated with ovarian hyper stimulation syndrome? (5)

A
  1. Hypovolemia
  2. Electrolyte imbalance
  3. Ascites
  4. Thromboembolism
  5. Pulmonary oedema
86
Q

How do we treat ovarian hyper stimulation syndrome? (5)

A
  1. Electrolyte monitoring/ correction/fluid balance
  2. Analgesia
  3. Thromboprophylaxis
  4. Drainage of ascites
  5. Rarely in severe cases termination of pregnancy
87
Q

What stops the sperm from meeting the egg? (3)

A
  1. Tubal damage - infection/surgery/adhesions
  2. Cervical problems
  3. Sexual problems
88
Q

Is IVF indicated to help women suffering from infertility secondary to infections conceive?

89
Q

What is Hysterosalpingogram (HSG)?

A

radio opaque contrast dye is
injected into the vagina through the cervix
Spillage of dye from fimbrial end is seen on X-Ray

HyCoSy- hysterosalpingogram contrast sonography-TVS and
insert opaque fluid

90
Q

What are the pros and cons of Hycosy?

A

Less invasive and no operative risks and anaesthetic risks

Risks are infection and anaphylaxis

91
Q

What is the laparoscopy and dye test used for?

A

Visualize and assess fallopian tubes

Methylene blue is injected from the cervix

Can also assess ovaries/adhesions/other pathology like
endometriosis

92
Q

What are the risks associated with laparoscopy and dye test?

A

Operative risks

Anaesthetic risks

93
Q

What investigations do we use for infertility?

A
  1. Hormone testing
  2. Hysterosalpingogram
  3. Hycosy
  4. laparoscopy and dye test
94
Q

What investigations do we offer women thinking of having IVF?

A

HIV + Hepatitis B +C

Screen for chlamydia trachoma’s

95
Q

What advice do we give women who want to conceive but are susceptible to rubella?

A

Offer them a vaccine and tell them to not get pregnant at least 1 month after taking the vaccine

96
Q

How is infertility secondary to ashermans treated?

A

Hysteroscopic adhesionolysis

97
Q

How is infertility secondary to endometriosis treated?

A

Medical treatment does not enhance fertility

Surgical management + adhesionolysis

98
Q

What predicts IVF success? (7)

A
  1. Success falls with rising female age
  2. Number of previous treatment cycles
  3. who have previously been pregnant and/or had a live birth
  4. BMI >30- success of assisted reproduction procedures.
  5. consumption of more than 1 unit of alcohol per day reduces
  6. maternal and paternal smoking can adversely affect the success
    rates of assisted reproduction procedures

7.maternal caffeine consumption has adverse effects on the
success rates of assisted reproduction procedures.

99
Q

What are the indications for assisted conception? (6)

A
  1. When other methods have failed
  2. Unexplained infertility
  3. Male factor
  4. Tubal blockage
  5. Endometriosis
  6. Genetic disorders
100
Q

When is intrauterine insemination used? (4)

A
  1. physical disability or psychosexual problem who are using
    partner or donor sperm
  2. Couples with cervical factors and sexual factors
  3. people in same-sex relationships
  4. Sperm are injected directly into the uterus
101
Q

What is IVF?

A

Embryos are fertilized outside and transferred into uterus

102
Q

What do we use to measure Ovarian reserve?

103
Q

Is ovarian reserve needed for IVF?

104
Q

What are the 4 stages of IVF

A
  1. Multiple follicular development
  2. Ovulation and egg collection
  3. Fertilization and culture
  4. Embryo transfer
105
Q

What is the Multiple follicular development stage of IVF?

A

Daily injection of FSH and LH for 2 weeks
GnRH
analogues are given to supress pituitary FSH and LH production

106
Q

What is the Ovulation and egg collection stage of IVF

A

Once optimum number of mature follicles (15-20mm) are confirmed

Stop GnRH analogues

Single injection of LH or hCG

Eggs are collected by TVS by aspiration

107
Q

What is the Fertilization and culture stage of IVF?

A

Eggs are incubated with the sperm and cultured

108
Q

What is the embryo transfer stage of IVF?

A

Two cleavage embryos are transferred with a 255 twin pregnancy rate

Luteal support with HCG or progesterone is given for 4-8 weeks

109
Q

Whats the maximum number of embryos transferred in an IVF cycle?

110
Q

What are the indications for intacytoplasmic sperm injection (4)

A
  1. severe deficits in semen quality
  2. obstructive azoospermia
  3. non-obstructive azoospermia.
  4. Prior to ICSI -genetic counselling and testing
111
Q

What is preimplantation genetic diagnosis

A

Blastocyst (day 5-6 embryo ) – DNA can be examined by PCR

Polymerase chain reaction

112
Q

What is preimplantation genetic diagnoses mainly used for?

A

cystic fibrosis , haemophilia

113
Q

What is surrogacy?

A

Congenital absent uterus/hysterectomy

Surrogate carries the pregnancy and delivers the child

Adopted by commissioning couple

Number of ethical issues involved

114
Q

What are the Indications for oocyte donation

A
  1. premature ovarian failure
  2. gonadal dysgenesis including Turner syndrome
  3. bilateral oophorectomy
  4. ovarian failure following chemotherapy or radiotherapy
  5. certain cases of IVF treatment failure
115
Q

What are the complications of assisted conception? (4)

A
  1. Superovulation- multiple pregnancy and OHSS
  2. Intraperitoneal haemorrhage and pelvic infection
  3. Ectopic pregnancy
  4. Increased chromosomal anomalies in babies born by ICSI

OBSTETRICS (11 decks)

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