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Obstetrics & Gynaecology > Subfertility and assisted Conception > Flashcards

Subfertility and assisted Conception Flashcards

1
Q

Definition of fecundity

A

The chance of conception for a couple over 1 month

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2
Q

Average fecundity for a couple under 32 y/o

A

20% per month

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3
Q

Statistics for rates of natural conception

A

20% of couples will conceive within 1 month
80% within 1 year
86% within 2 years
90% within 3 years

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4
Q

When do you begin to investigate subfertility

A

In all couples after 1 year of failing to conceive
Earlier should be offered to higher risk couples:
- women older than 35y
- history suggestive of anovulation, tubal disease or male factor problems

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5
Q

How common are male factor problems in fertility, what is the main cause

A

5% of men are subfertile

85% of these have suboptimal semen quality

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6
Q

Topics of causes of infertility

A 
Oocytes: ovulation, ovarian reserve, timing of sexual intercourse
Tubal factors (patency)
Other female factors: abnormal uterine anatomy
Male factors: suboptimal sperm, azoospermia, coital dysfunction, immune factors
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7
Q

Causes for anovulation/impaired ovulation

A

HPO axis disruption:

  • BMI higher than 29 or less than 19
  • PCOS (most common cause)
  • Hyper- or hypothryroidism
  • Hyperprolactinaemia
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8
Q

Cycle of ovulation

A

Primordial follicles - Pre-antral (primary) follicles - secondary follicles (oocyte + granulosa cells) - antral follicles (zonal pellucida) - dominant follicle - Ovulation - Corpus luteum development

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9
Q

Spermatogenesis cycle

A

Begins at puberty and continues throughout life
74 days to produce sperm
10 days to travel to head of epididymis
70% of mature sperm stored in head
Ejaculation - passage of sperm through vas deferens into urethra adjacent to prostate
7 day lifespan in uterus

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10
Q

What is azoospermia

A

Absence of MOTILE sperm in semen

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11
Q

Causes of fallopian tube obstruction

A

Previous pelvic inflammatory disease (e.g. chlamydia)

As a result of any inflammatory process in abdomen/pelvis ( surgery, endometriosis, IBD - all cause adhesions)

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12
Q

Causes of unsuccessful implantation

A

Abnormal endometrium:

  • Fibroids
  • Uterine adhesions (Asherman’s syndrome)
  • Uterine polyps
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13
Q

Cycle of oocytes in female lifetime

A

highest number in 2nd trimester of pregnancy in a female foetus
Sharp decrease during third trimester
Progressive decline in number of oocytes after birth
Complete depletion at menopause

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14
Q

Pre-conception advice

A 
Stop smoking
Moderate alcohol (no binges)
Avoid drugs (especially cones)
Moderate exercise
Optimise BMI
Avoid occupational exposures
Female: folic acid, vitamin B6 & B12, omega 3
Males: Vitamin E, selenium
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15
Q

Optimal timing of intercourse for conception

A

few days before ovulation to a few days after (ovulation always occurs 14 days before start of period)

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16
Q

How to tell when ovulating

A

Clear endocervical mucous (spinbarket - stringy and pliable)
Ferning on slide
Basal body temperature rises

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17
Q

Investigations of ovulation

A

Day 21 progesterone - rises in response to ovulation
Basal body temperature - rises in response to progesterone
LH kits - detect LH surge prior to ovulation
Cycle tracking - measure of oestrogen, progesterone and LH throughout cycle, performed by fertility specialist, can determine when ovulation has occurred

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18
Q

Investigating ovarian reserve

A

Relatively new, specialist test
“Egg timer test”
- perform on day 3-5 of cycle
- FSH, AMH and US of ovarian volume and antral follicle count
high FSH and low AMH indicates low reserve
Age-based test - compare to likely parameters at that age

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19
Q

History required when assessing sperm-related factors of subfertility

A

Fathered other pregnancies
Congenital issues (e.g. cryptorchidism)
Previous surgery/trauma/hernias/torsion
Infections (mumps orchitis, STIs - obstructed vas)
Other illnesses (cancer, CTx, CF)
Smoking, drinking, drugs
Occupational exposures (Solvents, radiation, mining chemicals)

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20
Q

When to perform semen analysis

A

3-4 days after sexual abstinence

2 abnormal results required to diagnose male subfertility

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21
Q

Normal parameters for semen analysis

A 
Volume more than 2mL
pH more than 7.2
Sperm conc more than 20M/mL
total sperm count more than 40M/ejaculate
Motility more than 50% grade a and b
Morphology more than 30% normal forms
22
Q

Tests indicated if low sperm count or azoospermia

A

testosterone levels
LH and FSH
screen for CF gene (congenital bilateral absence of vas deferens)

23
Q

Most common causes for subfertility and how common are they

A 
Ovulatory dysfunction 30%
Tubal Pathology 15%
Male factor 20%
Unknown cause 20%
Endometriosis 7%
Uterine causes 3%
Cervical causes 2%
Multiple causes 3%
24
Q

How common is subfertility

A

Affects 1 in 7 couples

25
Q

Assessing tubal patency in a patient with a low-risk history

A

Hysterosalpingogram - dye inserted into womb, watch its passage through tubes (reliable indicator of patency, not obstruction)
Saline hysterosalpingography - put ultrasound dye into womb and watch passage in tubes

26
Q

Assessing tubal patency in a woman with a high-risk history

A

Laparoscopy + dye

27
Q

Assessing a woman for congenital uterine anomalies

A

Best assessed by laparoscopy + hysteroscopy, saline hysterosalpingography or 3D ultrasound

28
Q

Assessing a male’s sexual function

A 
How often do you make love?
Do you get erections?
Can you penetrate partner deeply?
Do you reach an orgasm?
Do you ejaculate?
29
Q

Step-wise approach of assisted conception

A
  1. ovulation induction
    (clomifene citrate, laparoscopy ovarian drilling if polycystic, small dose FSH)
  2. Intrauterine insemination
  3. IVF/ICSI
30
Q

Outcome of clomifene citrate

A

70% of women will ovulate
Pregnancy rate of 10-15%
10% risk of pregnancy being multiple

31
Q

Mechanism of action of clomifene citrate

A

Blocks oestrogen receptors in hypothalamus - blocks negative feedback response - induces increased production of gonadotrophin releasing hormone - increased production of FSH - increased follicle production in ovaries - increased ovulation

32
Q

Indications for intrauterine insemination

A

Unexplained subfertility
Anovulation unresponsive to ovulation induction
Mild male factor
Minimal to mild endometriosis

33
Q

Intrauterine insemination procedure

A

Introduction of small sample of prepared sperm (from ejaculate, surgical retrieval, or donor sperm) into uterine cavity with fine uterine catheter
+ mild stimulation with FSH to produce mature follicles
Follicular tracking to avoid over or under stimulation

34
Q

Success rate of intrauterine insemination

A

15-20% success rate

35
Q

Indications for intrauterine insemination with donor sperm

A

Azoospermia
Single women
Same sex couples

36
Q

Management for women with low ovarian reserve

A

Prompt referral to specialist for fertility advice

37
Q

Associations of low ovarian reserve

A

Poor response to gonadotrophins (main form of fertility therapy)
Poor oocyte and embryo quality
Increased miscarriage rate

38
Q

Management options of subfertility in women with tubal pathology

A

Surgery - if pathology amenable to repair

In vitro fertilisation

39
Q

Indications for in vitro fertilisation

A

tubal pathology

Patients with no success following ovulation induction, intrauterine insemination and donor insemination

40
Q

Donor egg indications

A

Women with poor egg quality:
- older women
- premature ovarian failure
Previous surgery/chemo/radiotherapy which adversely affected ovarian function

41
Q

Success rate of IVF

A

in women under 35y - 30% success rate per cycle

42
Q

Procedure in IVF

A
  1. Ovaries stimulated with FSH (aim for 8-10 follicles)
    and Monitor for apporx 2 weeks
  2. Inject hCG to induce ovulation
  3. Collect eggs with US guided fine needle
  4. Fertilisation of eggs in petri dish (or intracytoplasmic sperm injection if required)
  5. Fertilised embryos replaced into uterine cavity
  6. Pregnancy test performed 2 weeks later
43
Q

Risks of IVF

A

Higher rate of ectopic pregnancies (3-4%)

Overstimulation of the ovaries (ovarian hyperstimulation syndrome)

44
Q

Ovarian hyperstimulation syndrome: cause and presentation

A

Iatrogenic due to increased FSH - increased follices - increased VEGF - increased capillary permeability

Ascites, hugely enlarged multi-follicular ovaries (painful), pulmonary oedema, multi-organ failure, coagulopathy

45
Q

Management options for male factor subfertility

A

FSH and hCG injections if primary hypogonadism
Intracytoplasmic sperm injection (present but low quality sperm)
Surgical sperm retrieval (if absence of naturally ejaculated sperm)

46
Q

Procedure of surgical sperm retrieval

A

Fine needle inserted into epididymis or testicular tissue to obtain sperm or testicular tissue with sperm respectively

Retrieved sperm can be cryopreserved or injected into the oocyte as a fresh IVF/ICSI cycle

47
Q

Pregnancy rate for thawed gametes following cryopreservation

A

Almost that of non-cryopreserved IVF

48
Q

Percentage of women with PCOS who have subfertility

A

75%

49
Q

Return to normal ovulation after ceasing OCP

A

Many women will return to normal menses and fertility within 30 days
All women should return to normal menses and fertility within 90 days

50
Q

Return to normal ovulation after removing an implanon

A

Levels of circulating etonogestrel undetectable within 1 week

Over 90% of women will ovulate within 3-4 weeks of removal

51
Q

Diagnostic criteria for PCOS

A

Rotterdam criteria (requires 2 out of 3)

  • oligo and/or amenorrheoa
  • Clinical and/or biochemical evidence of hyperandrogenism (raised FAI or free testosterone)
  • Polycystic ovaries on USS (8+ subcapsular follicular cysts under 10mm in diameter)

+ exclusion of conditions that may mimic PCOS (thyroid, CAH, prolactin etc.)

Obstetrics & Gynaecology (22 decks)

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