Subfertility & Early Pregnancy Flashcards
What is sub fertility defined as?
What is the prevalence
Failed conception after 1yr regular unprotected intercouse
Affects 15% couples
What are the 4 main conditions / stages of conception and what causes of sub fertility may affect each one
Egg produced - anovulation (PCOS)
Adequate sperm release - male factor
Sperm reaches egg - tubal damage, sexual /cervical probs
Embryo implantation - unexplained subfertility
What are some causes for damaged fallopian tubes? (3)
Infection
Endometriosis
Hydrosalpinx
Surgery / adhesions
List the causes of anovulation (7)
COMMON:
Hypothalamic hypogonadism (stress, anorexia, idio)
Hyperprolactinaemia (pituitary damage/tumour)
PCOS
Uncommon: Hypo/hyperthyroidism Adrenal hyperplasia Premature ovarian failure Gonadal dysgenesis Luteinised unruptured follicle syndrome
What investigations of ovulation can be done? (4)
Mid-luteal phase serum progesterone (elevated = ovulated)
LH-based urine predictors
USS follicular tracking
Temperature charts (unreliable)
What are the different fertility treatments for PCOS? (6)
Wt loss Clomifene (1st line) Metformin (2nd line) Gonadotrophin induction Laparoscopic ovarian diathermy IVF
What is clomifene, how does it work?
How is it given (in what regime)?
What are the risks with clomifene (2)
Anti-oestrogen, raises FSH+LH thus follicle maturation
Given on day 2-6 of cycle, for 6m
Risks: multiple pregnancy (multiple follicles) + endometrial thinning (assessed with transvag USS)
What is metformin, how does it work in sub fertility?
What are the advantages to using metformin > clomifene? (4)
Insulin-sensitising + oestrogen restoring
No risk multiple preg
Treats hirsutism
Reduce risk early miscarriage
Reduce risk gestational DM (common in PCOS)
How does gonadotrophin induction work in artificially causing ovulation?
What are the risks?
Recombinant/purified (menopausal urinary) FSH±LH
Follicle development monitored with USS
Follicle release stimulated by hCG injection (structurally similar to LH)
Risk: multiple preg (but reduced with low-dose step up)
How would laparoscopic ovarian diathermy help in sub fertility treatment? (2)
Treat adhesions / endometriosis
Test tubal patency (dye test)
How is hypothalamic-hypogonadism subfertility managed? (2)
Wt loss
Gonadotrophins if wt normal
How is hyperprolactinaemia subfertility managed? (2)
Bromocriptine
or
Cabergoline (blocks prolactin secretion)
What are some side effects of ovulation induction? (2)
Multiple pregnancy
Ovarian Hyperstimulation Syndrome (OHSS)
What are some RFs of OHSS? (3)
How can it be prevented?
Gonadotrophin induction
IVF (>ov induction)
<35yrs
Prevented by low-doses of induction
What types of infection can → PID? (3)
Chlamydia
post-IUD infection
Ruptured appendix
What anatomical changes occur in PID?
How can this be managed in sub fertility treatment?
Peritubal adhesions
Closed fibril ends (w. normal tubes)
Laparoscopic adhesiolysis + salpingostomy
What Ix can be done for tubal damage? (2)
Laparoscopy + dye test (w. hysteroscopy)
Hysterosalpingogram
What cervical problems can cause subfertility? (2)
Antibody production against sperm
Vaginal/cervical infection
What are the indications for assisted conception? (6)
Any/all other methods failed Unexplained sub fertility Male factor subfertility (intracytoplasmic sperm injection) Endometriosis Tubal blockage (standard IVF) Genetic disorders
What are the processes of normal IVF?
Follicle production
Egg collection + mix with sperm
Transfer / implant into uterus
What types of subfertility can intra-uterine semination be used for? (4)
+ not be used for? (1)
Used in: cervical, sexual, some male factor, unexplained
Not used in: tubal damage (still req patent tubes)
How are FSH + LH involved in spermatogenesis?
LH acts of Leydig cells → testosterone production
FSH + testosterone → Sertoli cells → synthesis + transport of sperm
Testosterone + other steroids inhib LH release (-ve feedback)
What is the normal concentration of sperm in semen?
And normal level of motility?
Normal: >15million sperm/ml
Motility: >32%
What are the different ranges of low sperm count?
<15 million / ml = oligospermia
<5 million / ml = severe oligospermia
Zero = azoospermia
Absent/low motility = asthenospermia
What are some causes of low sperm count? (7)
Smoking Alcohol Drugs Chemicals Inadequate local cooling Genetic factors Antisperm Abs Idiopathic
What interventions can be done for:
Oligospermia
Mod-severe
Azoospermia
Oligo = intra-uterine insemination Mod-severe = IVF ± ICSI Azoo = examine for presence of vas deferens + karyotype
What is the incidence of ectopic pregnancy?
What are the RFs? (6)
1%+ of pregnancies
Older Smoking Endometriosis PID Previous ectopic Previous surgery
When / how will ectopic pregnancy present?
- Acute (4)
- Sub-Acute (6) (3S + 3S)
Presents at 4-10wks amenorrhoea
ACUTE:
Abdo pain + Shock (tachycardia + → hypotension)
Syncope + shoulder tip pain (= intraperitoneal blood loss)
SUBACUTE: Abdo pain (colicky → constant) Dark PV bleeding Lower abdo tenderness Cervical excitation Adnexal tenderness Smaller uterus than expected/os closed
What investigations can be done regarding ectopic pregnancy? (6)
Urine hCG - for all repro women w. abdo pain / bleeding
Serum hCG (can detect earlier in gestation)
USS (transvag if serum hCG >1000; transabdo if >6000)
Speculum
Bloods: FBC / G&S / Cross-Match
Laparoscopy
What is the immediate management of ectopic pregnancy if symptomatic? (4)
→ Admit to hosp: NBM IV access Anti-D if Rh-ve Consider resuscitation + transfusion
When is medical management of an ectopic carried out? What criteria (3)
What does it involve? (2)
if hCG <3000
Unruptured
No fetal cardiac activity
IM methotrexate w/o laparoscopy
Serial hCG to confirm trophoblastic tissue gone (may need 2nd dose)
What happens in a molar pregnancy / gestational trophoblastic disease? (2)
What is the incidence
What are the RFs (2)
Aggressive trophoblastic proliferation
+ excess hCG secretion
0.1-0.2% pregancies
RFs: extreme repro age + asian
What are the different classifications of molar pregnancy / gestational trophoblastic disease (4)
Hyatidiform mole (Complete/Partial) - localised non-invasive
Invasive mole - malignant tissue within uterus
Choriocarcinoma - metastasis occurred
What are the features of a molar pregnancy ? (4)
What is a complication
How is it Dx? (2)
PV bleed (poss heavy)
Severe vomiting
Large uterus
Early pre-eclampsia + hyperparathyroidism
Complication: recurrence (1 in 60 subsequent pregs)
Dx confirmed histologically but serum hCG v high
How is molar pregnancy managed? (3)
Suction curettage (ERCP) Avoid pregnancy + COC Monitor any rising hCG levels (would suggest malignancy)
What embryological events happen from fertilisation → implantation?
Fertilised in ampulla → zygote + peristalsis / ciliary action
Enters uterus by day 4 as multicellular morula
→ Becomes fluid filled blastocyst + trophoblast outer layer
Implants at day 6-12
What does the trophoblastic tissue do upon invasion? (2)
Produces hCG → maintains CL (oestrogen/progesterone → keeping endometrium secretory with glycogen/lipids)
Trophoblast formation → chorionic villi formation
What is miscarriage defined as?
What are the different types? (6)
= death <24wks
Threatened miscarriage Inevitable Incomplete Complete Septic Missed
What will be seen O/E with each type of miscarriage (6)
Threatened - Bleeding, FHR, uterus normal enlarged/ os closed
Inevitable - bleeding, os open
Incomplete - some fetal parts passed, os open
Complete - all fetal parts passed, uterus not enlarged/ os closed
Septic - foul discharge, tender uterus, fever, abdo pain/peritonism
Missed - no FHR only recognised until bleeding/USS, smaller uterus/ os closed
What Ix can be done in the case of a miscarriage?
USS (less useful in ectopics)
hCG
FBC
RhGrp
What are the 3 different options of management in a non-viable intrauterine miscarriage?
Expectant: for incomplete / missed - watch&wait
Women willing + no signs infection
Medical: prostaglandin ± anti-progesterone
Surgical: ERPC (GA + vacuum aspiration)
Indications: heavy bleeding/ signs infection
What is the incidence/definition of recurrent miscarriage?
What are the different causes (6) + Tx
= >3 successive miscarriages → in 1% couples
Antiphospholipid Abs → Aspirin + LMWH Chromosomal defects Anatomical factors Infection PCOS Lifestyle/other: obesity, smoking, caffeine, older
