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Module 203, Theme 2- Reproductive System, Fetal Development, Pregnancy and Birth > T2 L7 Causes and Treatment of Subfertility > Flashcards

T2 L7 Causes and Treatment of Subfertility Flashcards

1
Q

What are the requirements for conception?

A

Progressively motile normal sperm capable of reaching and fertilizing the oocyte

Timely release of a competent oocyte

Free passage for the sperm to reach the oocyte and for the embryo to reach the uterus

A mature endometrium that allows implantation

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2
Q

What is infertility?

A

Inability to conceive after 2 year of frequent unprotected intercourse

Reasonable to investigate after 1 year unless there is a concern

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3
Q

What is the cumulative probability of pregnancy after 1, 2 and 3 years?

A

84%, 92% & 93% after 1,2 & 3 years

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4
Q

Why is fertility defined as being “after 2 years of frequent unprotected intercourse”?

A

The gap of the cumulative probability is bigger between 1 and 2 years

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5
Q

What is the NICE definition of infertility?

A

“The period of time people have been trying to conceive without success after which formal investigation is justified and possible treatment implemented”

“If a woman has not conceived after a year, offer further clinical assessment and investigation, along with her partner”

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6
Q

What are the various causes of infertility?

A
  • Unexplained 30%
  • Ovulatory 27%
  • Male factor 19% (now 25-30%)
  • Tubal 14%
  • Endometriosis 5% (this is present in 10-15% of women)
  • Other factors 5% (uterine, endometrial, gamete or embryo defect)
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7
Q

What % of infertility cases was due to infertility problems in both the male and female?

A

39%

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8
Q

What are the indications for early referral/investigation in a female?

A
  1. Aged over 35 years
  2. Amenorrhoea/oligomenorrhoea
  3. Previous abdominal/pelvic surgery
  4. Previous PID/STD
  5. Abnormal pelvic examination
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9
Q

What are the indications for early referral/investigation in a male?

A
  1. Previous genital pathology (history of testicular maldescent, surgery, infection or trauma, there is a greater incidence of abnormal semen parameters)
  2. Previous STD
  3. Significant systemic illness
  4. Abnormal genital examination
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10
Q

Describe a “normal result” in a semen analysis

A

Count > 15 x 10^6 / ml

Motility > 40%

Morphology > 4%

Volume 1.5-6 mls

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11
Q

What is the most common cause for oligo/azoospermia?

A

Primary testicular failure

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12
Q

What is non-obstructive azoospermia?

A

No spermatogenesis (could be due to hypogonadotropic hypogonadism)

These men usually have a smaller penis

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13
Q

What causes obstructive azoospermia?

A

Blockage of the epididymis and the vas deferens

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14
Q

Which conditions should you consider if the sperm count is < 5 million?

A

Y chromosome microdeletion

Cystic fibrosis

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15
Q

What is the single, most important factor for infertility in females?

A

AGE

A woman’s fertility declines with age

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16
Q

Why does a woman’s fertility decrease with age?

A

Decline in oocyte number and quality rather than uterine receptivity

The increased rate of chromosomal abnormalities in the oocyte also results in higher aneuploidy and miscarriage rates

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17
Q

If a woman is over 45 years old, what is she advised to consider if she is trying to get pregnant?

A

Advised to consider egg donation, because the chance of having a live birth decreases due to an increase in chromosomal abnormality

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18
Q

How is the female assessed for infertility?

A

Screen for chlamydia & Rubella

Ovarian reserve

  • Early follicular phase hormone level (FSH, LH & E2)
  • AMH (Anti-Mullarian Hormone)
  • AFC (Antral Follicle Count)

Ovulation test

Tubal test

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19
Q

What is AMH? When is it produced in a female?

A

Anti-mullerian hormone

First produced by the granulosa cells of the early growing follicle

It continues to be produced by the granulosa cells of growing follicles up until the early antral stage after which it declines precipitously

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20
Q

When do the granulosa cells stop producing AMH in females?

A

Once they reach 8mm

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21
Q

What happens to the concentration of AMH during the monthly period?

A

Remains constant

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22
Q

How is AMH used in fertility assessment (of a female)?

A

Circulating AMH may accurately reflect the total developing follicular cohort

This may represent the total ovarian reserve

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23
Q

What happens to the concentration of AMH as age increases?

A

It reduces

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24
Q

How many days is a regular menstrual cycle in most women? During this period, what will most women undergo?

A

26-35 days

Women who have regular menstrual cycles will ovulate

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25
Q

What is BBT and how is it used? What are NICE guidelines on BBT?

A

BBT = Basal Body Temperature
Used to monitor ovulation

NICE guidelines advice against use of BBT

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26
Q

What other ways can ovulation can be monitored?

A
  • Ovulation detection kits
  • Cervical mucous pattern
  • Follicular tracking or mid-luteal phase P4 (7 days before menstruation)
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27
Q

What levels of mid-luteal P4 is accepted as evidence of ovulation?

A

30nmol/L

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28
Q

What else can make the mid-luteal P4 > 30nmol/L?

A

A leutinised unruptured follicle, which has not released an egg yet

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29
Q

What is a more reliable method for monitoring ovulation (in comparison to mid-luteal P4)?

A

Follicular tracking

NOTE: This method is costly & labour intensive

30
Q

What is the most common cause of anovulation and primary or secondary oligo/amenorrhea?

A

PCOS (polycystic ovarian syndrome)

Makes up 85% of cases

31
Q

What test could you do to confirm oligo/amenorrhea?

A
  • FSH/LH
  • E2
  • prolactin
  • TFT
  • androgens & SHBG
32
Q

What happens to the levels of FSH/LH and E2 in PCOS?

A

normal FSH/LH & E2

33
Q

What % of anovulation and primary or secondary oligo/amenorrhea is due to POF?

A

5%

34
Q

What happens to the levels of FSH/LH and E2 in POF?

A
  • high FSH

- low E2

35
Q

What % of anovulation and primary or secondary oligo/amenorrhea is due to hypogonadotrophic hypogonadism?

A

10%

36
Q

What happens to the levels of FSH/LH and E2 in hypogonadotrophic hypogonadism?

A
  • low FSH, LH

- low E2

37
Q

What is the most common cause of tubal damage?

A

PID (pelvic inflammatory disease)

-secondary to chlamydia

38
Q

What are different types of tubal disease/damage?

A
  • proximal (25%)

- distal – fimbriael end of the tube (75%)

39
Q

What are the risk of tubal damage after 1, 2, or 3 episodes of pelvic infection?

A
  • 12% after one episode
  • 23% after two episodes
  • 54% after three episodes
40
Q

Name other causes of tubal damage

A
  • septic abortion
  • ruptured appendix
  • pelvic surgery
  • ectopic pregnancy
41
Q

What are the different imaging that can be done to examine the fallopian tubes?

A

Hysterosalpingogram (HSG)

Hysterosalpingo-contrast-ultrasonography (HyCoSy)

Laparoscopy & dye

42
Q

If there is a low risk of tubal disease which imaging technique should be offered?

A

HSG

HyCoSy

43
Q

Why should you screen for chlamydia before carrying out imaging?

A

By injecting the dye into the cervix, the Chlamydia trachomatis can be pushed towards the fallopian tube

44
Q

When is HSG carried out?

A

2-5 days after menstruation

45
Q

Why should antibiotics be given when doing a HSG?

A

To prevent the flare-up of infection

if there is a history of PID (pelvic inflammatory disease)

46
Q

What is the overall risk of infection when doing a HSG? How does this differ in high-risk populations?

A

1%

In high-risk population this can rise to 3%

47
Q

What are the advantages and disadvantages of HSG?

A

Advantages:

  • relative safety
  • ease of use
  • delineation of the uterine cavity and Fallopian tubes

Disadvatages:
-inability to assess the pelvic peritoneum

NOTE: this is an ideal screening test for the majority of the patients

48
Q

Describe HyCoSy

A

Similar to HSG

Ovarian and uterine assessment is possible

49
Q

What are the advantages and disadvantages of HyCoSy?

A

Advantages
-No radiation = Relatively safer

Disadvantage
-Time-consuming & requires training

50
Q

What are the advantages and disadvantages of lap & dye?

A

Advantage

  • more sensitive & specific
  • chance to diagnose & treat endometriosis & adhesions

Disadvantage
-invasive procedure with inherent risks of visceral injury to the patient

51
Q

Name the uterine abnormalities estimated to be a factor in 10-15% of couple seeking fertility treatment

A
  • adhesions
  • polyps
  • submucous fibroids and septae
52
Q

What imaging techniques can be used to detect the uterine abnormalities?

A

HSG (hysterosalpingogram)

TVS (transvaginal ultrasound)

hysteroscopy

53
Q

Which imaging technique is the best at detecting uterine abnormalities?

A

Hysteroscopy

54
Q

What drug is used to induced in women that have PCOS?

A

Clomid (Clomifene Citrate)

It has an anti-oestrogen effect on hypothalamic pituitary axis. It inhibits negative feedback of oestrogen on gonadotropin release.

55
Q

What drug is used to induced in women that have resistant PCOS or Hypogonadotrophic Hypogonadism?

A

FSH injections

56
Q

What is the risk of ovulation induction?

A

Multiple pregnancies

NOTE: Monitor 1st cycle using USS (to make sure that the woman is responding but not excessively)

57
Q

What is IUI? What are the indications for using this treatment?

A

Intrauterine insemination

Indications

  • unexplained
  • mild male factor
  • mild endometriosis
58
Q

What are the advantages of IUI treatment?

A
  • Less stress
  • Less invasive
  • Less tech
  • Cheap
59
Q

What is the success rate of IUI treatment?

A

10% (per cycle)

60
Q

What are the NICE guidelines on IUI treatment?

A

Do not offer IUI for couples who have unexplained infertility

IUI for single women, same sex couple or heterosexual couple who have problem with intercourse

IVF for couples who have unexplained infertility

61
Q

What are the main indications for IVF?

A

Tubal damage

Low sperm quality

Unexplained infertility

Low ovarian reserve (time is of the essence and the couple needs to go for the most effective treatment which is IVF)

62
Q

What occurs in Controlled Ovarian Hyperstimulation?

A

Ovulation by multiple ovarian follicles is induced

The multiple follicles can be taken out by oocyte retrieval (egg collection) for use in in vitro fertilisation (IVF)

63
Q

How frequently does an ultrasound examination and blood take place, during IVF? Why?

A

Every other week for IVF

To make sure that the woman is responding to treatment but not excessively

64
Q

How are the eggs collected? How long does this take?

A

Collected using needle using ultrasound guidance

Collection takes approximate 20 minutes

NOTE: The woman is either sedated or under general anaesthetics

65
Q

What is intra-cytoplasmic sperm injection?

A

The sperm is directly injected into the egg (used in men with a low sperm count)

66
Q

What are the risks associated with intra-cytoplasmic sperm injection?

A

Higher risk of congenital/chromosomal abnormality. This could be because the sperm from men with a low sperm count are more likely to have genetic abnormalities

67
Q

When is the embryo transferred to the uterus?

A

Most embryo transfers occurs at day 5

At this stage the embryo is better synchronised with the endometrium which is more ready for implantation

68
Q

What is the national average for IVF live birth rates (LBR)?

A

30-35% (< 35 year old)

69
Q

What is the IVF live birth rates dependent on?

A

Depends on female partner’s age

The unit IVF is being carried out in. The LBR varies from one unit to another

70
Q

From which age is the success rate of frozen embryos bigger than fresh embryos?

A

40 years

Module 203, Theme 2- Reproductive System, Fetal Development, Pregnancy and Birth (17 decks)

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