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MFSRH 2021 > Subfertility > Flashcards

Subfertility Flashcards

1
Q

% infertility due to male partner?

A

25%

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2
Q

% infertility due to female partner?

A

40%

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3
Q

Mixed male and female infertility %?

A

15%

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4
Q

% unexplained infertility?

A

20%

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5
Q

If clomifene/tamoxifen failures to be successful in fertility tx in PCOS next line?

A

Metformin, ovarian drilling or gonadotrophins (drilling sometimes preferred as no risk of multiple pregnancy)

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6
Q

Mechanism of action for clomifene?

A

Non-selective oestregen receptor antagonist (feedback loop disruption of oestrogen –> gonadotrophin release and ovarian stimulation).

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7
Q

Risk factors for OHSS?

A

PCOS, increased antral follicle count, high AMH, multiple pregnancy.

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8
Q

Mechanism of action of metformin in subfertility in tx in PCOS?

A

Normalises response to FSH promoting ovulation by reducing insulin resistance and hyperandrogenism

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9
Q

If a semen analysis is abnormal what should be the next step in subfertility investigation?

A

Repeat 3/12 (spermatogenesis 90 days)

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10
Q

% IVF success rate for <35?

A

30%

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11
Q

% success rate for IVF 36-38yo?

A

15%

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12
Q

% success rate for IVF 39 yo?

A

10%

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13
Q

% success rate IVF >40 yo?

A

6%

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14
Q

Risk factors for ovarian hyperstimulation syndrome?

A

Previous OHSS, PCOS, Low BMI.

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15
Q

Pathophysiology of OHSS?

A

Fluid shift to extravascular space resulting in peritoneal and pleural fluid, fluid shift results in haemoconcentration and increased VTE risk

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16
Q

Risk of OHSS in IVF?

A

0.5-10%

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17
Q

Features of OHSS?

A

Abdo pain, ascites, hypovolaemic shock, pleural effusion, thrombosis, renal failure, death

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18
Q

% OHSS severe?

A

0.5%

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19
Q

Treatment of OHSS?

A

Supportive and discontinue IVF cycle, VTE prophylaxis (TEDs/LMWH), hydrate appropriately, analgesia, antiemetics.

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20
Q

What is the most common sex chromosome disorder associated with infertility?

A

Klinefelter’s syndrome

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21
Q

Questions to ask man when couple is struggling to conceive?

A

Previous children, time TTC, frequency of SI, contraception use, any infections in past esp mumps/C4, previous genital surgery, systemic illnesses, medications, ejaculation/erectile dysfunction, occupation, lifestyle (smoking, ETOH, drugs, steroids, BMI).

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22
Q

What to examine in a male when couple is struggling to conceive?

A

Secondary sex characteristics, genitals (esp testicular size), gynaecomastia.

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23
Q

First ix of male when couple if struggling to conceive?

A

Semen analysis

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24
Q

If 2 x semen samples are abnormal what ix next for male?

A

Testosterone/LH/FHS/prolactin, consider imagining genital tract/karyotyping

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25
Q

In a male with oligospermia and a low testosterone and raised LH/FSH what is likely to be the causes of the oligospermia?

A

Primary problem with spermatogenesis – primary hypogonadotrophic hypogandism

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26
Q

Causes of primary hypogonadotrophic hypogandism in males?

A

Genetic (Klienfelters, y chromosome microdeletion), Cryptorchidism, acquired (mumps, medications, radiation)

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27
Q

If a male with subfertility has a low FSH/LH and testosterone what is the likely cause?

A

Secondary hypogonadotrophic hypogandism (pituitary level).

Pituitary adenoma (ACTH, cortisol, TSH, ILGF-1, prolactin), congenital GnRH deficiency (Kellmanns, usually reduced/absent smell), head trauma/surgery/tumour

28
Q

Tx of Secondary hypogonadotrophic hypogandism in a male?

A

External GnRH (3 x weekly with monitoring of testosterone levels and sperm count) if tx of underlying cause doesn’t improve sperm count in 6/12

29
Q

Likely cause of infertility in a male with normal FSH/LH/testosterone and azoospermia?

A

Sperm transport disorder eg obstructive azoospermia (anywhere in the transport) or congenital absence of vas, USS and testicular biopsy.

30
Q

Risk factors for retrograde ejaculation?

A

Surgery
diabetes
spinal cord injury

psych meds (chlorpromazine, thioridazine and antihypertensives (doxazosin)

31
Q

How to diagnose retrograde ejaculation?

A

Sperm present in urine

32
Q

Medical tx for retrograde ejaculation?

A

Symopathomemetic (ephedrine sulphate or phyylpropanolamine) if meds failed assisted conception

33
Q

% chance of fatherhood in a person with bilateral cryptorchism?

A

35-50%

34
Q

% chance of fatherhood in a person with unilateral cryptorchism?

A

94%

35
Q

3 categories of male infertility causes?

A

Congenital, acquired, idiopathic

36
Q

Causes of genetic male infertility?

A

Klinefelter’s, Kallman, AIS

37
Q

Testicular causes of male subfertility?

A

Genetic (Kleinfelters, Noonan’s, Kallman’s)

Cryptorchidism

Acquired
(injury, varicocele, tumours, chemo / radiotherapy, idiopathic)

38
Q

Causes of pre-testicular male subfertility?

A

Hypothalamic disease
(Kallmans, Prader-Willi, CHARGE)

Pituitary pathology
(Tumours, Brain injury including iatragenic)

39
Q

Post testicular causes of male subfertility?

A

Can’t get through or can’t swim

Congenital
(congenital absence of the vas deferens, CF, Youngs)

Acquired
(Infection, vasectomy),

Sperm dysmotility 
(Immotile cilia syndrome, Maturation defects, Immunological infertility, Globozoospermia, Sexual dysfunction)
40
Q

What hormone controls spermatogenesis?

A

FSH (LH controls testosterone production)

41
Q

Which cells produce testosterone in males?

A

Leydig

42
Q

Which cells are the location of spermatogenesis?

A

Sertoli

43
Q

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

A

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

A further half will conceive with a further 6 cycles.

cumulative pregnancy rate ~ 75%

44
Q

% of couples of will conceive within 1 year of trying?

A

80%

45
Q

% of couples of will conceive within 2 years of trying?

A

90%

46
Q

Semen analysis normal total sperm/ejaculate?

A

> 39 million

47
Q

Semen analysis normal sperm/ml?

A

> 15 million

48
Q

Where does sperm maturation take place?

A

Epididymis

49
Q

Normal pH of sperm?

A

> 7.2

50
Q

Normal ejaculate volume?

A

> 1.5ml

51
Q

Normal motility or progressive motility on semen analysis?

A

> 40% motile, >32% progressively motile.

52
Q

Normal vitality of semen analysis?

A

> 58%

53
Q

Normal morphology on semen analysis?

A

> 4%

54
Q

How long trying to conceive until referral for ix?

A

12/12 if <35, no menstrual or structural problems (PID/fibroid), or undescended testes. 6/12 otherwise.

55
Q

Low and high BMI of women impacting on fertility?

A

<19 and >29

56
Q

Initial investigation for a couple with infertility?

A

Semen analysis and assessment of ovulation status.

57
Q

Initial assessment of ovulation (for infertility ix) in women with regular cycle?

A

Mid luteal phase progesterone (day 21 if 28 day cycle)

58
Q

% infertility due to tubal patency?

A

20%

59
Q

% infertility due to ovulatory disorders?

A

21%

60
Q

Initially assessment of ovulation (for fertility ix) in women with irregular cycles?

A

FSH, LH, prolactin, TFTs (add in testosterone and oestradiol if suspecting PCOS, if hirsute/virilised)

61
Q

Method to assess for tubal damage?

A

Lap and dye if comorbidities (ectopic/pid/endometriosis) if no comorbidities HSG. HyCoSY also possible

62
Q

Is an endometrial biopsy indicated in infertility investigation

A

? No

63
Q

Assessment of ovarian reserve?

A

Day 3 of cycle: AMH, antral follicle count, FSH

64
Q

1st line induction of ovulation in infertility?

A

Clomifene for 6/12 (if PCOS USS in first month to assess response)

65
Q

Risk of multiple pregnancy in clomifene use?

A

5-10%

MFSRH 2021 (13 decks)

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