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OBGYN > Subfertility/Infertility > Flashcards

Subfertility/Infertility Flashcards

1
Q

What is infertility?

A

no chance of conception

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2
Q

What is subfertility?

A

Lower chance of conception

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3
Q

What is the definition of sub fertile?

A

A couple is sub fertile if conception has not occurred after 1 year of regular unprotected vaginal intercourse

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4
Q

What is regular intercourse?

A

Not less than 2 times a week

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5
Q

How common is subfertility?

A

15% of couples affected

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6
Q

What is primary subfertility?

A

Couple without a prior pregnancy

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7
Q

What is secondary subfertility?

A

Couple with a prior pregnancy (incl miscarriage, TOP)

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8
Q

What is the requirement of normal pregnancy?

A

Have to have egg, sperm, these need to meet and fertilise and then finally implant

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9
Q

What do the NICE guidelines suggest are the causes of subfertility?

A
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10
Q

What are the peak fertility years for females?

A
  • peak in late teens, early 20s
  • > 35 it becomes an issue
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11
Q

When is a male considered fertile?

A

Spermatogenesis at puberty and fertile >60

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12
Q

What are some general impacts on fertility?

A
  • BMI = anorexia (women <19) and obesity (>30)
  • C2H5 intake (women should have none while TTC and men should stay within recommended guidelines)
  • smoking
  • ? Tight fitting briefs in men (elevated scrotal temp?)
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13
Q

How can you reassure someone trying to conceive about the effectiveness of natural conception?

A
  • 80% of couples will be pregnant after 12 cycles (1 year)
  • of those who have not conceived after 12 cycles, about 50% will conceive after a second year of attempted conception (90% overall after 2 years)
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14
Q

What general advice would you give to a couple who is trying to conceive?

A
  • regular intercourse 2-3 times a week
  • don’t recommend temp charts, LH detection devices, intercourse around time of ovulation as can put added strain on couple
  • modifiable risk factors = smoking, alcohol, drug use and weight
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15
Q

What pre-conception also advice is given to a couple who are TTC?

A
  • folic acid
  • rubella status +/- immunisation
  • cervical check
  • control of chronic illness (eg DM, epilepsy, stopping any teratogenic meds
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16
Q

What questions do you ask in the female history when investigating fertility?

A
  • age
  • past pregnancies
  • types of contraception previously use and when stopped
  • Sx suggesting ovulatory problems = menstrual disturbance, galactorrhea, hirsutism, acne, weight, stress, thyroid disease
  • Sx suggesting tubal, uterine, cervical factors = PID, STIs, abdominal/pelvic surgery, IMB, PCB, smear history, dyspareunia, dysmenorrhea (endometriosis)
  • past med Hx = thyroid disease, DM, CF
  • meds incl chemo
  • lifestyle factors = smoking, alcohol intake, drugs
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17
Q

Why can CF impact fertility in a woman?

A

Thicker cervical mucus

Ovulation problems

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18
Q

What questions do you ask as part of male history when investigating fertility?

A
  • weight
  • previous children with other partners
  • Hx suggesting 1* spermatogenic failure - history of genital tract infections (eg mumps orchitis, prostatitis, STIs), surgery or trauma to male genital/inguinal region, previous urogenital abnormality (eg undescended testis)
  • sexual = ejaculatory or erectile dysfunction
  • past med hx = neoplasia, DM, CRF, Thyrotoxicosis, CF
  • meds incl chemo
  • exposure to lead, cadmium, radiation
  • lifestyle factors = alcohol, smoking, drug use, stress, social or occupational situations that may cause testicular hyperthermia
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19
Q

What questions should be asked of both the male and female when investigating fertility?

A
  • previous pregnancies together or with other partners
  • length of time trying to conceive
  • frequency of intercourse
  • difficulty/discomfort with intercourse
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20
Q

What should be looked at as part of the female exam when investigating fertility?

A
  • general examination
  • BMI
  • 2* sexual characteristics
  • galactorrhea (hyperprolactinaemia)
  • hirsutism/acne (PCOS)
  • pelvic exam
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21
Q

What should be looked at while doing a male examination when investigating fertility?

A
  • general exam
  • BMI
  • assessment of 2* sexual characteristics (eg sexual hair, build (decreased in hypogonadism)
  • gynaecomastia (hypogonadism)
  • scrotal exam - lumps (cancer, varicocele, hernia), small soft testes (hypogonadism), undescended testes
  • penis exam = position of urethral meatus
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22
Q

When can semen analysis be done?

A

After 3 days of abstinence

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23
Q

How should semen be collected for semen analysis?

A
  • collect in sterile plastic container after masturbation
  • analysed within 1-2 hrs
  • if abnormal repeat in 12 weeks
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24
Q

What should be done if semen analysis comes back as abnormal?

A

Repeat after 12 week

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25
Q

What should be done if semen analysis comes back as azoospermia?

A

Repeat immediately

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26
Q

What is azoospermia?

A

No sperm present

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27
Q

What is oligospermia?

A

<15 million/ml

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28
Q

What is severe oligospermia?

A

<5 million/ml

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29
Q

What is asthenospermia?

A

Absent of low motility

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30
Q

What is teratozoospermia?

A

Excessive number of abnormally formed sperm

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31
Q

What are the normal parameters of a semen analysis?

A
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32
Q

What is the difference between aspermia and azoospermia?

A

Aspermia = a lack of semen

Azoospermia = no sperm within the semen

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33
Q

What are some other factors that can be looked at outside of the normal semen analysis?

A

MAR test: mixed agglutination reaction: abs to sperm in blood, cervical mucus or semen. Steroids/IUI/IVF as tx.
Liquefaction time: complete in 30-60 mins
Vitality> 75% of sperm alive

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34
Q

What are potential causes of abnormal semen analysis? (10)

A
  • idiopathic oligospermia & asthenozoospermia
  • infections - epididymitis, orchitis
  • radiotherapy
  • cryptorchisism
  • CF (congenital absence of vas deferens)
  • varicocoele (? Why impairs fertility)
  • surgery (retrograde ejaculation after TURP)
  • endocrine: raised PRL, kallmann’s syndrome, diabetes
  • antisperm Abs (esp after reversal of vasectomy)
  • klinefelters syndrome (normal intellect, small testes, infertile)
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35
Q

What investigations would you do for abnormal semen analysis? (What labs for azoospermia)

A
  • exam scrotum
  • labs: in azoospermia = FSH, LH, testosterone, prolactin, TSH +/- karyotype
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36
Q

What management can be done for mild-moderate oligospermia?

A

Intrauterine insemination

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37
Q

What management can be done for moderate to severe oligospermia?

A

IVF

38
Q

What management can be done for severe oligospermia?

A

Intracytoplasmic sperm injection - IVF

39
Q

What management can be done for azoospermia?

A

Surgical sperm retrieval (+ ICSI-IVF)

Donor sperm

40
Q

What are hypothalamic causes of ovulation failure? (5)

A
  • stress
  • altered BMI (include anorexia)
  • exercise
  • drugs (exogenous gonadotrophins)
  • kallmanns syndrome (genetic failure of GnRH production)
41
Q

What thyroid issue can cause ovulation failure?

A

Hypo & hyperthyroid

42
Q

What pituitary issues can cause ovulation failure? (3)

A
  • Hyperprolactinaemia
  • tumours
  • Sheehan’s syndrome
43
Q

What adrenal issues can cause ovulation failure?

A
  • Cushing’s syndrome
  • CAH
44
Q

What ovarian issues cause ovulation failure? (4)

A
  • PCOS
  • premature ovarian failure
  • gonadal dysgenesis (ovary imperfectly formed due to abnormalities of X chromosome)
  • luteinized unruptured follicle syndrome
45
Q

What pancreas issue can cause ovulation failure?

A

Uncontrolled diabetes

46
Q

What can be sued to aid detection of ovulation?

A
  • history:
  • regular cycles
  • vagina spotting, discharge, pelvic pain (mittelschmerz) at time of ovulation
  • examination generally not done
  • body temp drop 0.2C pre ovulation and rise 0.5C post ovulation
47
Q

What investigations can be done to detect ovulation?

A
  • mid luteal progesterone
  • D21 progesterone of 28 day cycle (or menstruation -7)
  • u/s = follicule growth and corpus luteum development
  • OTC urine kits - check LH surge
  • analysis of cervical mucus
48
Q

What tests might be done to check for ovulation failure?

A
  • FSH, LH, oestradiol (day 2-4), TFTs, prolactin, testosterone, SHBG, AMH
  • mid luteal progesterone
49
Q

How might AMH indicate what the cause of ovulation failure is?

A

Normal AMH: 1.5-4ng/ml:

high in PCOS, low in ovarian failure

50
Q

What is not recommended for testing for ovulation failure?

A
  • basal body temp charts
  • use of ovulation predictor kits
51
Q

What else is PCOS called?

A

Stein-Leventhal syndrome

52
Q

What are the hallmark features of PCOS?

A
  • polycyclic ovary (20%) - 12 or more follicles (small immature, no dominance)

Or

  • an enlarged ovary >10ml
53
Q

What are the diagnostic features of PCOS (5%)?

A

2 out of 3 of:

  • PCO on u/s
  • irregular periods (>35 days or 6-9 menses/year)
  • hyperandrogenism: clinical (acne, hirsutism) or biochemical (raised testosterone)
54
Q

How does PCOS appear on u/s?

A

String of pearls appearance

55
Q

What are the non-medical ways to manage PCOS?

A

lifestyle = smoking cessation, weight loss

56
Q

What are the medical ways to handle PCOS?

A
  • clomiphene
  • metformin
  • gonadotrophins
  • laparoscopic ovarian diathermy
57
Q

What is the pathology underlying PCOS?

A

Genetic and environmental (body weight) factors

Disordered LH production and insulin resist-hyperinsulinaemia

58
Q

What pathology causes PCOS?

A

increased androgens

  • raised LH and hyperinsulinameia lead to increased ovarian and adrenal androgen production
  • hyperinsulinaemia leads to decreased SHBG production which increases free androgen

Results in:
* disruption of folliculogenesis - ovarian follicles & irregular or absent ovulation
* clinical hyperandrogegism - hirsutism and acne

59
Q

What are the clinical features of PCOS?

A
  • Presentation can vary
  • miscarriage, infertility, type 2 diabetes, endometrial cancer
60
Q

What is the rate of diabetes with PCOS?

A
  • up to 50% T2DM
  • 30% GDM
61
Q

Why does PCOS increase the risk of endometrial cancer?

A

Unopposed estrogens - need at least 3-4 bleeds/year to protect endometrium

62
Q

What lab investigations would you do for PCOS? (6)

A
  • FSH (n)
  • LH (>10IU/L)
  • prolactin (n/mildly raised = 25-40)
  • greatly raised 500-800 think tumour
  • TSH (n)
  • testosterone (>2.5nmol/L and <4.8nmol/L)
  • note if way higher think of CAH or androgen secreting tumour
  • can also use LH:FSH ratio 3:1
63
Q

What other investigations would you do for suspected PCOS?

A
  • U/S = TVUS
  • screening for diabetes and hyperlipidaemia
64
Q

What are the 2 approaches to management of PCOS?

A
  • symptoms
  • fertility
65
Q

How can the symptoms be managed in PCOS?

A
  • diet and exercise (all symptoms)
    lower insulin
  • COC (menstruation & hirsutism)
    regular period
    suppresses ovarian androgen production
    increases SBHG production
    can worsen insulin resistance
  • metformin (promotes ovulation, treat hirsutism)
    insulin sensitiser
  • antiandorgens (hirsutism)
    cyproterone acetate (Diane-35)
    spironolactone
  • topical eflornithine (hirsutism)
66
Q

How is the induction of ovulation done in cases of PCOS?

A
  • lifestyle = smoking cessation, restoration of normal weight
  • treat specific causes = thyroid and hyperprolactinaemia
  • medications to specifically induce ovulation or other methods
67
Q

What methods are spefically used to induce ovulation in PCOS?

A
  • clomifene
  • metformin
  • laparoscopic ovarian diathermy
  • gonadotrophins
68
Q

How is Clomifene given to induce ovulation in PCOS?

A

50mg/day

Day 2-6 of cycle

Limited to 6 months

69
Q

What is Clomifene?

A

Non-steroidal, antioestrogenic (SERM)

70
Q

How does Clomifene work to induce ovulation in PCOS?

A

Blocks negative feedback therefore high FSH/LH

(Only an agonist when the prevailing levels of oestrogen are very low: otherwise an antagonist)

71
Q

How must a patient be monitored while taking Clomifene?

A

TVUS (at least first cycle)
* ovarian response
* endometrial thickness (can thin as anti-estrogen)

72
Q

What is the success rate of Clomifene?

A
  • ovulation rate 70%
  • live birth rate 40%
  • multiple pregnancy 10%
73
Q

How is dose escalation done for Clomifene?

A

100mg or 150mg

74
Q

How does metformin induce ovulation?

A
  • insulin sensitiser
  • promotes ovulation
  • can be used alone or in combo with Clomiphene (in clomiphene resistant ladies)
75
Q

What are the advantages of metformin as a way to induce ovulation in PCOS?

A

Nil risk of multiple pregnancy

Treats hirsutism

? Continue into pregnancy to lower GD and miscarriage

76
Q

How do you carry out laparoscopic ovarian diathermy?

A

Each ovary, few points, few seconds

77
Q

When are Gonadotrophins used to induce ovulation?

A
  • human recombinant FSH +/- LH or purified urinary if failure of clomiphene or hypothalamic problem
  • when follicle reaches correct size (~17 mm) stimulate ovulation with HCG or recombinant LH
78
Q

What are some of the complications of ovulation induction?

A
  • multiple pregnancies
  • ovarian hyperstimulation syndrome (OHSS)
79
Q

What is this?

A

OHSS

80
Q

What is this?

A

Ovarian hyper stimulation syndrome (OHSS)

81
Q

What can cause OHSS?

A

Gonadotrophin (and rarely clomiphene) overstimulate the follicles which can get very large and painful

82
Q

How can OHSS be prevented?

A

Lowest effective dose, monitor follicles with u/s (withdraw GN if excessive growth)

83
Q

What causes OHSS?

A

Leakage of fluid from intravascular space to third space

84
Q

What is seen in severe cases of OHSS? (6)

A
  • hypovolaemia
  • electrolyte abnormalities
  • ascites
  • pulmonary oedema
  • thromboembolism
85
Q

What do you admit the patient with OHSS for?

A
  • IVF
  • electrolyte monitoring
  • fluid drainage
  • thromboprophylaxis
86
Q

What factors may prompt earlier referral of a woman with fertility issues?

A
  • age >35 yrs
  • amenorrhea/oligomenorrhea
  • previous abdominal/pelvic surgery
  • previous PID
  • previous STI
  • endometriosis
  • abnormal pelvic exam
  • significant systemic illness (eg DM, renal disease)
  • known reason for infertile (eg prior treatment for cancer)
87
Q

What are some causes of failure of gamete transfer or embryo transport?

A
  • tubal blockage:
  • infection (PID, IUD)
  • endometriosis
  • ectopic pregnancy
  • surgery/adhesions

*uterine:
- leiomyomas (fibroids): if large enough to distort the uterine cavity or block the tubes
- intrauterine adhesions (ashermans syndrome)

  • cervical problems:
  • antisperm antibodies
  • problems a/w/ cervical/vaginal infections
  • prev cone biopsy
  • sexual:
  • impotence
  • dyspareunia (eg endometriosis)
88
Q

What investigations can be done for tubal patency?

A
  • hysteroscopy, Lap and Dye: methylene blue
  • hysterosalpinogram/HyCoSy: radio-opaque contrast - may miss endometriosis and lateral adhesions
89
Q

What treatments may be done for tubal issue in fertility?

A

Tubal surgery:
- adhesinolysis
- salpingostomy
+/- assisted conception

90
Q

What treatments are done for cervical problems causing fertility issues?

A
  • ? Steroids if ASA
  • IUI
  • IVF
91
Q

What treatment is done for impotence causing fertility issues?

A

Psychosexual counsellor

OBGYN (25 decks)

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