1
Q
What is the absolute risk of aortic dissection in pregnancy in women with Turner S?
A
1%
2
Q
When is pregnancy contraindicated in Turner syndrome?
A
If aorta has an absolute diameter of >35mm
or
25mm/m2 and there is a history of aortic surgery or there is uncontrolled hypertension despite treatment
3
Q
Any considered risk factors with pregnancy in TS?
A
The presence of a bicuspid valve or coarctation
4
Q
What is the risk of miscarriage after natural conception for women with TS
A
31-45%
5
Q
Maternal complications for TS in pregnancy with donor oocytes or embryos
A
-miscarriage rates appear to be similar to the general population 25%
-increased risk of hypertension - 15-17%
-aortic dissection 1-2%
- CS rates 80-100%
6
Q
Fetal complications for TS in pregnancy with donor oocytes or embryos
A
-preterm birth incidence is higher - 12-38%
-SGA (weighing less than 2500g 18-57%
7
Q
Chances of conception in couples with in one year
A
80%
- need to be less than 40 and have regular intercourse
8
Q
Chances of couple conceiving in 2 years
A
Of those who do not conceive in the first year - half will conceive in the Second year- cumulative preg rate over 90%
9
Q
Inform people who have IUI that…
A
their fertility that:
o over 50% of women aged under 40 years will conceive within 6 cycles of intrauterine
insemination (IUI) of those who do not conceive within 6 cycles of intrauterine
insemination, about half will do so with a further 6 cycles (cumulative pregnancy rate
over 75%).
Inform people who
10
Q
Sperm - frozen or fresh
A
Fresh
11
Q
AFC
Low
Mod
High
A
Low - less than 4
Mod 4-16
High more than 16
12
Q
FSH
A
Low - more than 8.9
Mod- 4- 8.9
High - less than 4
13
Q
AMH
Low
Mod
High
A
Low <5.4
Mod 5-25
High >25
14
Q
If irregular cycles how to check for ovulation?
A
repeat progesterone weekly after initial possible mid lateral phase
15
Q
What can be surgically managed ? And what not?
A
Obstructive azoospermia should be offered surgical correction of epididymal blockage - surgical correction should be considered as an alternative to surgical stem recovery and IVF
No surgical treatment for varicoceles as a form of of fertility treatment
16
Q
Clomid - how long to take
A
No longer than 6 months
17
Q
If on clomid what do you do
A
Offer USS at least in the first cycle of treatment to ensure they are taking a dose that minimizes the risk of multiple pregnancy
18
Q
GNRH agonists
A
Only offer gonadotrophin-releasing hormone agonists to women who have a low risk of ovarian hyperstimulation syndrome.
When using gonadotrophin-releasing hormone agonists as part of IVF treatment, use a long down-regulation protocol.
19
Q
Embryo transfer strategies in IVF into uterine cavities
A
Replacement of embryos into a uterine cavity with an endometrium of less than 5 mm thickness is unlikely to result in a pregnancy and is therefore not recommended.
20
Q
Transferring fresh or frozen embryos
Under 37
A
In the 1st IVF - use a single embryo
In the 2nd cycle use a single embryo if 1 or more top quality embryos are available
-consider 2 embryos if no top quality there
In the 3rd cycle - no more than 2 embryos
21
Q
Transferring fresh or frozen embryos
Age 37-39
A
In the 1st and 2nd ful IVF cycle use single embryo transfer if there are 1 or more top-quality embryos
-consider 2 if no top quality
In the 3rd cycle - transfer no more than 2 embryos
22
Q
Transferring fresh or frozen embryos
Age 40-42
A
Consider double embryo transfer
- no more than 2 embryos should be transferred during one cycle
- where a top-quality blastocyst is available use a single embryo transfer
23
Q
Treatment for luteal phase of pregnancy is
A
Progesterone for 8 weeks no longer , not HCG
-if you give HCG in IVF it can increase chance of ovarian stimulation
24
Q
Indications for ICSI (4)
A
Quality obstructive
Severe deficits in semen
Non-obstructive azoopspermia
Azoospermia
25
Karyotyping with ICSI?
Where the indication for ICSI is a severe deficit of semen quality or non- obstructive azoospermia, the man's karyotype should be established.
26
Post donor insemination if failed what to do?
If failed 3 times or 3 cycles - offer tubal assessment
27
Oocyte donation when
Gonadal dysgenesis (turners
Bilateral oophorectomy ovarian failure following chemo or radio
Certain cases of IVF treatment failure
Can be considered in high risk if genetic condition passing of
28
Male subfertilty rates
Sixteen percent of couples will fail to conceive after 1 year of trying.1 A male factor alone is thought to contribute in up to 30% of these cases,
29
Causes of male infertility
Preterticular
● Hypothalamic disease
‐ Gonadotrophin deficiency (Kallman syndrome)
● Pituitary disease
‐ Pituitary insufficiency (tumours, radiation, surgery) ‐ Hyperprolactinaemia
‐ Exogenous hormones (anabolic steroids, glucocorticoid excess, hyper- or hypothyroidism)
↓Fsh ↓lh
Hypogonadotrophic hypogonadism
30
Causes of male infertility
Testilular
Testicular:
● Congenital
Genetic
‐ Chromosomal (Kleinfelter syndrome 47, XXY)
‐ Y chromosome microdeletions
‐ Noonan syndrome (male Turner syndrome 45, XO)
Other
‐ Cryptorchidism
● Acquired
‐ Injury (orchitis, torsion, trauma)
‐ Varicocele
‐ Systemic disease (renal failure, liver failure) ‐ Chemotherapy, radiotherapy
‐ Testicular tumours
‐ Idiopathic
Hypergonadotriphic hypogonadism or
High FSH, normal testosterone and LF
31
Post testicular male subfertility
Post-testicular (obstruction):
● Congenital
‐ Cystic fibrosis, congenital absence of the vas deferens (CAVD) ‐ Young’s syndrome
● Acquired
‐ Vasectomy
‐ Infection (chlamydia, gonorrhoea)
‐ Iatrogenic vasal injury
● Disorders of sperm function or motility
‐ Immotile cilia syndrome
‐ Maturation defects
‐ Immunological infertility
‐ Globozoospermia
● Sexual dysfunction
‐ Timing and frequency
‐ Erectile/ ejaculatory dysfunction
‐ Diabetes mellitus, multiple sclerosis, spinal cord/pelvic injuries
32
Male factor subfertility
Post- testicular
Post-testicular (obstruction):
● Congenital
‐ Cystic fibrosis, congenital absence of the vas deferens (CAVD) ‐ Young’s syndrome
● Acquired
‐ Vasectomy
‐ Infection (chlamydia, gonorrhoea)
‐ Iatrogenic vasal injury
● Disorders of sperm function or motility
‐ Immotile cilia syndrome
‐ Maturation defects
‐ Immunological infertility
‐ Globozoospermia
● Sexual dysfunction
‐ Timing and frequency
‐ Erectile/ ejaculatory dysfunction
‐ Diabetes mellitus, multiple sclerosis, spinal cord/pelvic injuries
33
What is the mean byline of a testicle in an adults
A mean volume of 20 ml in the adult is considered normal Consistency can be described as firm (normal), soft or hard (abnormal).
34
Most common sex chromosomal abnormality in men
Kleinefelter syndrome 47 XXY
35
Microdeletions on Y chromosome
As many as 10–15% of men with azoospermia and 5–10% of men with severe oligospermia have underlying micro-deletions in one or more gene regions implicated in spermatogenesis, on the long arm of the Y chromosome (Yq).
This region includes the Azoospermia Factor (AZF) locus, which contains three subregions: AZFa, AZFb, and AZFc. AZFc micro-deletions have a good prognosis for surgical sperm recovery whereas the prognostic value for sperm recovery in AZFa and AZFb micro-deletions is poor51 and such individuals should not be offered surgical sperm retrieval.
36
Imaging with absent vas def?
If an absent vas is detected on examination, a renal ultrasound scan is recommended, as up to 30% of such men may have a renal abnormality.
Do CF test if absent Vas Def
37
Testicular biopsy specimens can be classified histologically
normal (appropriate number of cells with complete spermatogenesis)
hypospermatogenesis (all cell types present and in correct ratio but at reduced cell number
maturation arrest (failure of spermatogenesis beyond a certain stage; can be ‘early’ or ‘late’)
sertoli cell-only (del Castillo) syndrome (no germ cells).
38
Treatment for pre testicular
GNRH or exogenous gonadotrophins
39
Types of azoospermia
40
Alzoospermia how much is obstructive
40%
41
UK fertility clinics must comply with
1. Human fertilization and embryology HLE act 1990
2. The HFE 2008
42
Definition of POI
FSH > 25IU/L on 2 samples 4 weeks apart
43
Genetic causes of POI
Turner’s syndrome
Fragile x
Autosomal disorders including galactosaemia
44
Outcomes of live births of fresh vs frozen donor oocytes
56.4% fresh vs 45.3% frozen
45
Main risk factors for complications using donated oocytes is
Severe pre-eclampsia
46
Do endometiromas recur
Yes 30% in 2-5 years post op
81% occur int he treated ovary
47
How common are endometriomas
17-44%
One third of them have bilateral cysts
48
What is the gold standard for endo diagnosis
MRI and advanced USS are considered as first line
49
Deep endo with endometrioma?
50% of women with deep endo will have an associated endometrioma
50
POI after bilateral systectomie for endometrioma is
2.4%
51
Risk of infection pelvic infection with and endometrioma undergoing egg collection is
<1%
Antibiotics are recommended as good practice for women with endometriosis undergoing ART are they are considered to be a high risk of pelvic infection
52
What improves AMH medication wise
Dienogest
53
Is there uterine remodeling with endo in preggo ppl
Only partial vascular remodeling in endo
Absent remodelling in PET
Increases preterm birth , premature rupture of membranes and FGR
54
Effect of altered juntional zone and vasculature bed remodelling in endo with preg
Placenta Praevia (deffective implantation )
55
Defective placentation effect on pregnancy
SGA FGR
PET
Preterm birth
56
Rate of sponsors hemorrhage in preg
19-55%
57
Unprovoked intrapersonal lede in in pregnancy incidence rate
1 in 10 000
58
Fetal mortality in the 3rd trimester with sponatous haemorrgae in pregnancy
31%
59
Endo and risk of uterine rupture?
In nulliparous women both before and during labor or uterine scar weakness, following excision of rectovaginal nodule or electrosurgical treatment of stage 4 endo
60
Pathophysiology of SHip - spontaneous haemoperitonium in pregnancy
Common -
-Involution of decidualised (progesterone mediated) endometriosis implants - associated with parametrial veins causing vascular fragility and spontaneous peritoneal bleeding (very rare)
-chronic inflammation - causes tissues affected by endo to be more friable
61
For high risk endo group:
Preconception counseling
Increased risk of miscarriage rate, PIH, PET, GA STD, PP, CS PPH neonatal admission
Increased risk of perineal injuries - 3rd, 4th, deg tears at vag del in cases o recto vag endo
62
For high risk endo group
Antenatal care
At cons led unit
BP monitoring
Consider aspirin
Endometrioma surveillance on USS
Serial growth scans for SGA and rout out PP
63
For high risk endo group
Intrapartum
Continuous CTG
Increased risk of failed induction of labour and obstructed labour
Early recourse to caesarean section in case of unexplained , abdo pain, hypotension, haematuria, since risk of SHIP , urethral rupture and uterine rupture even in nuliparous snowmen in unscarred uterus
Senior obstetrician to be present at CS in prev surgically treated endo.
64
Preferred imaging modality in pregnancy with endo
MRI with doalinium is adnantegous , USS is limited by the large uterus
65
Women with endo are at risk of what when menopause and endo
Women with endo have an increased risk of cardiovascular disease irrespective of whether they had an early surgical menopause
66
Increased risk of miscarriage with endo?
Yes, potential increased risk of miscarriage and ectopic pregnancy in 1st timester
67
For deep endometriosis involving the bowel, bladder or ureter,
consider:
pelvic MRI before operative laparoscopy
• a 3-month course of GnRHa before surgery.
Consider hormonal treatment after laparoscopic excision or
ablation.
68
If hysterectomy is indicated:
For endo (in nice guidelines)
excise all visible endometriotic lesions at the time of
hysterectomy
• discuss with the person what a hysterectomy is, its risks &
benefits, related treatments and likely outcome.
69
Average pregnancy rates after ICSI
33%
70
How can sperm be retrieved
Either from the testes or from the epididymis for IVF or ICSI-indications + obstructive causes severe male factor infertiltly - ejaculatory failiure
Super from the epididymis can be retrieved bia MESA- micro surgical or PESA epididymal sperm aspiration under local anaesthetic
71
Can you treat low FSH and low LH in men (hypogonadiptriphic hypogonadism ?
Yes with GNRH or exogenous gonadotrophins
72
Indications for IUI
Mild male factor infertility - up to 6 cycles
Immunologic infertility
Mechanical problems
NICE- mild oligozoospernia one or more variables below the 5th centile (as defined by the WHO, 2010).
73
Test for female hypogonadotrophic hypogonadism
Day 2-5 FSH and LH
74
If 50mg of clomid don’t work yet then what do you do
Increase to 100mg of clomid
75
Causes of subfertility rates
Unexplained
25%
In about 40% of cases disorders are found in both man and women
76
Causes of subfertility rates
Ovulatory disorders
25%
77
Causes of subfertility rates
Tubal damage
20%
78
Causes of subfertility rates
Factors in the male causing infertility
30%
79
Causes of subfertility rates
Uterine or peritoneal disorders
10%
80
What is the general incidence of subfertility
15% - 1 in 7 heterosexual couples in the UK
81
what are the WHO ovulation disorders
1
and treatment
1 - hypothalamic pituitary failure
stress ,anorexia , exercise induced
treatment - increase BMI if <19
reduce exercise if high
pulsating GNRH or gonadotriophons with LH activity to induce ovulation
82
what is the WHO ovulation disorder group II and treatment
Hypothalamic pituitary ovarian dysfunction
PCOS
weight loss off BMI >30
clemifene/clomiphere 1st line
metformin 1st line
lap. drilling 2ndline
gonadotrophin 2nd line
83
what. is the WHO ovulation disorder group III and treatment
ovarian failure
IVF with donor eggs
84
what is the management of hyperprolactinaemia
investigate cause eg MRI head for pituitary adenoma , meds review, some anti physchotics meds can cause prolactin rise
treatment = dopamine agonist - bromocriptine
85
what is the scoring system for hirsutism
ferryman and Gallwey
10% incidence in most populations
86
what are the causes for hirsutism
MC PCOS - 75%
acromegaly/adrogen secreting tumors
drugs
87
treatment for hirsutism
COCP
cyproterone acetate
spironolactone
finasteride
flutamide
insulin-sensitizing drugs
eg. metformin/pioglitazone
eflornithine
gonadotrophin releaseing hormone eg goserelin
88
what to test if secondary male subfertilty -
1st do physical exam - check for hair distribution, gynaecomastia and testes size
then check testosterone, prolactin and FSH, LH.
89
which obs complication is most common if had bariatric surgery
SGA
no difference in :
GDM
PET
IOL
CS
PPH
agars
NICU admission or perinatal death
90
Types of testicular failures
91
how does ovarian drilling help sub fertility
help to reduce the excessive ovarian stroma that these ovaries have.
This helps to reduce the amount of ovarian androgen producing tissue with the concomitant reduction in LH and normalising of the hyperandrogenaemia that is contributory to anovulation.
92
Should men of immunosuppressant non biologic medication like leflunomide conceive?
NO- this is for RA- they need to wait for 6 months post taking the meds and a wash out treatment has been given
women taking it need to stop for 2 years
93
what investigation to do if secondary sub fertility with CS and sepsis
TVS
to check for hydrosalpinx pre lap and lie or hystersalpingogram
94
meds that cause hyperprolactinaemia
metoclopramide
SSRIs
Calcium channel blockers
Oestrogen and anti androgens
amphetamines
dopamine depleting agents eg methyldopa
H2RAs. eg. cimetidine ranitidine
opioids
phenothiazines eg chlorpromazine
butyrophenones eg. haloperidol
benzamides eg metoclopramide
95
what level is progesterone if true anovulation
less than 10
also concurrent use of NSAIDS may also cause low or borderline progesterone levels
96
what is the acceptable weight gain in preg for post bariatric surgery
5-7kg while doing GTT
delay pregnancy for 1 year after beriatric surgery
dumping syndrome can be provided by 75g of GTT
no increase in preterm deliveries or congenital anomalies
97
what % of antispern antibodies is considered insignificant
<50% v
98
what is the hycosy false positive rate vs an HSG
13 vs 50%
99
what is the best time to do a HSG
best time during the follicular phase soon after menstrual bleeding has ceased and before ovulation
100
is there a marked association between chlamydia antibody titre and tubial damage
yes, if no chlamydia /antibody tests indicated a <15% likelihood of tubal pathology
a positive test may represent a cross reaction to antibodies to C. pneumoniae which is present in 50% of the general population.
101
varocolele what are they caused by?
formed by retrograde flow on the internal spermatic vein
102
do we treat varicocele ?
no , The precise association between varicoceles and sperm counts is unknown but the NICE and Cochrane reviews do not recommend treatment of these to improve sperm concentrations.
Varicoceles are the most common abnormality noted in male infertility evaluation, detected in approximately 40% of infertile men, but there is no evidence that treatment of small varicoceles improves fertility.
103
what can mumps orchiditis cause
primary testicular failure
(high FSH. and LH - low testosterone)
104
how does liver and pancreatic disease affect iron overload
lower production of SHBG from th liver can increase lev els of free circulating androgens which will suppress FSH and LH from pituatualuy and hence spermatogenesis
105
Is IUI inferior to IVF for unexplained sub fertility
No its is not inferior
106
classification of Obesity BMI
Classification BMI (kg/m2 )
Underweight < 18.50
Normal range 18.50–24.99
Overweight ≥ 25.00
Preobese 25.00–29.99
Obese class I 30.00–34.99
Obese class II 35.00–39.99
Obese class III ≥ 40.00
RCOG Green-top Guideline No. 126 e71 of e106 ª 2018 Royal College of Obstetricians and Gynaecologists
107
how to do GDM testing post bariatric surgery
fasting and 2hr post prandial BMs at home for a week at 26-28w
107
which nutrition deficiencies exist post especially malabsorption surgery - bariatric one - should be supplemented too
b12, folate
iron
calcium
don't need supplementation - but can be low - fat soluble vitamins , plasma protein levels
107
how does obesity affect male fertility ?
In the man, it can contribute to subfertility by causing:
DNA damage to sperm,
decreasing libido and
causing erectile dysfunction.
In the woman, it alters the follicular environment and leads to oocyte incompetence and suboptimal embryo quality, impairing implantation by negatively influencing the endometrium.
107
what is the ideal weight gain in pregnancy
7-11 kg
108
what is the difference between obese and non obese women and live birth rates after first ART cycle
Women with a BMI of > 30kg/M2 have up to 70% lower risk of having a live birth compared to those with BMI< 30kg/M2
109
what is the activity level for a obese women trying to conceive ?
Moderate intensity for at least 60−90 minutes on five or more occasions each week
110
what is the most common complication of PCOS
Obstructive sleep apnea , by. 30 times
111
what are the indications for donor insemianation
-obstructive azoospermia
- non-obstructive azoospermia
- severe deficit in semen quality in couples who do not wish to undergo ICSI
OR
*consider* donor insemination:
Where there is a high risk of transmitting a genetic disorder to the offspring
-Where there is a high risk of transmitting infectious disease to the offspring or woman from the man
- Severe rhesus iso-immunisation.
112
gold standard for diagnosis of MRKH
MRI
113
what are bicornuate uterus complications in pregnancy
pregnancy loss
preterm delivery
malpresentation
114
what is the risk for pregnancy if Turners woman gets IVF with donor oocyte donation
GDM
115
what is the rate of conception on the first year
80%
Inform people who are using artificial insemination to conceive and who are concerned about their fertility that:
Over 50% of women aged under 40 years will conceive within 6 cycles of intrauterine insemination (IUI)
Of those who do not conceive within 6 cycles of intrauterine insemination, about half will do so with a further 6 cycles (cumulative pregnancy rate over 75%).
116
what are the characteristics of hereditary galacosemia
cataracts
POI - can be primary or secondary amenorrhea or oligomenorrhea
117
Definition of POI in NICE
FSH > 30 4-6 weeks apart
Menopause timing depends on two key factors: peak follicle count and rate of follicular atresia
Women or girls with a small follicle pool at birth or experiencing and accelerated depletion of follicles through apoptosis develop POI
118
which HRT / estrogen is best for POI and best for bone mineralization and cardiovascular health
17b- estradiol is more beneficial than COCP
119
how to diagnose absence of the vas deference
clinical examination
120
if going through IVF need uss when ?
at day 7-9 and 11-14
121
what is ovarian hyperthecosis
Ovarian hyperthecosis is a condition where the ovarian stroma (supporting tissue) develops diffuse nests of luteinized theca cells, which produce large amounts of androgens.
* It is considered a severe form of PCOS on the spectrum of hyperandrogenic ovarian disorders.
* More common in postmenopausal women, but can occur earlier.
⸻
🔹 Pathophysiology
* Theca cells in the ovary normally make androgens (testosterone, androstenedione), which granulosa cells then convert to estrogens.
* In hyperthecosis, there is diffuse luteinization of stromal theca cells → excessive androgen production → virilization and metabolic issues.
* Often associated with insulin resistance and obesity, which further stimulates ovarian androgen production.
⸻
🔹 Clinical Features
* Hyperandrogenism:
* Hirsutism (facial/body hair)
* Male-pattern baldness
* Deepened voice
* Clitoromegaly (more severe than PCOS)
* Metabolic features:
* Insulin resistance, obesity, type 2 diabetes, metabolic syndr
Menstrual disturbances:
* Oligomenorrhea or amenorrhea (similar to PCOS)
* In postmenopausal women: unexpected virilization is a red flag.
⸻
🔹 Diagnosis
* Lab findings:
* Markedly ↑ testosterone (often higher than in PCOS).
* Normal or mildly ↑ DHEAS (rules out adrenal source).
* Imaging:
* Ovaries may appear enlarged and hyper-echoic on ultrasound, but not always cystic.
* Histology: nests of luteinized theca cells in stroma.
⸻
🔹 Complications
* Severe virilization
* Endometrial hyperplasia/cancer risk (from unopposed estrogen, similar to PCOS)
* Metabolic syndrome & cardiovascular disease risk
⸻
🔹 Management
* Medical:
* Weight loss, insulin sensitizers (metformin)
* Anti-androgens (spironolactone, finasteride)
* Definitive:
* Bilateral oophorectomy in severe or refractory cases, especially postme
122
after rubella immunization how long to avoid pregnancy
1 month
123
what is obstructive sleep apnea an independent risk factor for
cardiovascular disease
124
what are the indications for prolactin measurements
galactorrhea
ovulation disorder
pituitary tumour
125
parameter used to predict overall chance of success through natural conception or IVF
maternal age
126
what percentage of men with CF are infertile ?
98%
127
Turner's want to have kids, how to they do that?
IVF with donor eggs oocytes
128
Approx. percentage of IVF pregnancies that lead to twins
25%
129
when does oocyte retrieval happen after hcg Injeections
34-37h
130
Frozen thawed embryo replacement increases the overall cumulative pregnancy rate by approximately how much percent ?
11%
131
% of women needing to be admitted to hospital with severe or moderate OHSS
1%
132
what is the optimal endometrial thickness in mm for frozen-thawed embryo replacement cycles
7-12mm
Ideally over or equal to 8
133
Inseminated oocytes are checked for signs of fertilisation after approximately how many hours ?
18h
134
how does duration of infertility affect ART success rate
The longer the duration of infertility, the lower the chances of success with assisted reproduction techniques.
135
what is the half life of clomiphene -
5-7 days
it is an antiestrogenic agent
associated with higher incidence of OHSS, multiple pregnancy
it is a selective oestrogen receptor modulator
it increases the production of gonadoptiohins (FSH) by inhibiting feedback on the hypothalamus
136
what % of women will ovulate with clomid
80%
137
how much does a BL salpingectomy increase birth rate if BL hydrosalpinx
A systematic review has concluded that laparoscopic salpingectomy should be considered prior to IVF as this significantly raises live birth rate (72% with two to three cycles of treatment) compared with 24% following tubal surgery.
138
where to put the filshie clip
on the isthmus
The uterine manipulator should be used to improve visualization and accuracy by straightening the fallopian tube.
The clip should be placed perpendicular to the isthmic portion of the tube, about 2 cm from the uterine cornue.
139
breast cancer patient on tamoxifen plans for pregnancy when t stop tamoxifen
3 months prior
Tamoxifen has a long half life so three months is recommended to allow the drug to clear the body before trying to conceive.
Other factors to be considered are if any imaging is likely to be necessary in the near future, and predicted life expectancy if a woman has metastatic disease.
140
which hormonal level is affected by ART conception
PAPP -A
141
first hormone to be deficient in Sheehans syndrome
growth hormone
142
what is Sheehan syndrome and what does it cause
causes infertility and eye brow loss
Sheehan’s syndrome = postpartum pituitary necrosis → hypopituitarism → hormone deficiencies → needs lifelong replacement.
Sheehan’s syndrome is hypopituitarism (decreased pituitary gland function) that occurs after severe blood loss or very low blood pressure during or after childbirth.
The pituitary gland—especially in pregnancy—becomes enlarged and has higher blood supply needs. If there’s a massive postpartum hemorrhage (PPH), the pituitary can become ischemic (low blood flow) and undergo necrosis (tissue death).
⸻
Cause
* Trigger: Severe postpartum hemorrhage or hypotension.
* Mechanism: Reduced blood supply → ischemic necrosis of the anterior pituitary → hormone deficiencies.
⸻
Hormones Affected
Mainly anterior pituitary hormones:
* ↓ Prolactin → failure to lactate
* ↓ Gonadotropins (LH, FSH) → amenorrhea or oligomenorrhea
* ↓ TSH → secondary hypothyroidism (fatigue, *cold intolerance*, weight gain)
* ↓ ACTH → secondary adrenal insufficiency (low cortisol, fatigue, hypotension, hyponatremia)
* ↓ GH → low energy, poor quality of life
The posterior pituitary (ADH, oxytocin) is usually spared because it has a different blood supply.
Symptoms
* Failure to breastfeed (earliest sign)
* Absent or scant menstruation after delivery
* Fatigue, low blood pressure, dizziness
* Loss of pubic/axillary hair
* Hypothyroidism-like symptoms (cold intolerance, weight gain, dry skin)
* Adrenal insufficiency symptoms (weakness, low sodium, shock if severe)
* Can present immediately postpartum or years later, often subtly.
⸻
Diagnosis
* History: Severe postpartum hemorrhage, failure to lactate.
* Labs: Low pituitary hormones and their target hormones (e.g., low cortisol + low ACTH, low free T4 + low TSH, etc.).
* MRI: Small or empty sella turcica in chronic cases.
⸻
Treatment
* Lifelong hormone replacement therapy, tailored to deficiencies:
* Hydrocortisone or prednisone (for cortisol deficiency)
* Levothyroxine (for hypothyroidism)
* Estrogen ± progesterone or gonadotropins (for ovarian function/menstrual cycles)
* Growth hormone (sometimes, in selected patients)
143
what is increased risks are increased in IVF
congenital anomalies and cerebral palsy
144
can you use clomid is BMI is above 30
yes
145
what is the sensitivity of hystero-salpingography in detecting tubal obstruction
65%
146
when to repeat test is severe oligospermia
in 2-4weeks
147
what is klinefelters syndrome
Klinefelter’s syndrome is a genetic condition in males caused by having an extra X chromosome.
Normal male karyotype = 46,XY
Klinefelter’s = 47,XXY (most common), but variants like 48,XXXY also exist.
⸻
Key Features
* Hypogonadism (small testes, low testosterone)
* Infertility (due to impaired spermatogenesis)
* Tall stature with long legs and arms (eunuchoid body habitus)
* Gynecomastia (male breast development, ↑ breast cancer risk)
* Reduced facial and body hair
* Learning difficulties or language delay (but intelligence is usually in the normal range)
⸻
Hormone Profile
* Low testosterone
* High FSH and LH (hypergonadotropic hypogonadism, because the testes don’t respond properly)
Diagnosis
* Karyotype testing (chromosomal analysis)
* Hormonal testing (low testosterone, high gonadotropins)
⸻
Treatment
* Testosterone replacement therapy (improves secondary sexual characteristics, mood, bone health, muscle mass)
* Fertility options: sometimes sperm retrieval + assisted reproductive technology
* Educational and psychological support
⸻
👉 In short:
Klinefelter’s syndrome = 47,XXY male → tall, small testes, infertility, gynecomastia, learning difficulties → needs testosterone replacement.
148
ovarian hyperthecosis is associated with increased risk of
Endometrial hyperplasia
149
what are the types of OHSS
Category
Features / Criteria
Mild OHSS
* Abdominal bloating/discomfort* Mild abdominal pain* Ovarian enlargement, size usually < 8 cm
Moderate OHSS
* All mild features + worsening: * Moderate abdominal pain and discomfort * Nausea ± vomiting * Ultrasound evidence of ascites (fluid in abdomen) * Ovarian size 8-12 cm
Severe OHSS
* Clinical ascites (i.e. obvious fluid in abdomen) ± hydrothorax (fluid in chest) * Oliguria (reduced urine output), e.g. < 300 mL/day or < 30 mL/hour * Haematocrit > ~0.45 (haemoconcentration) * Ovarian size > 12 cm * Possibly hypoproteinaemia, and other lab derangements
Critical OHSS
* Tense ascites and/or large hydrothorax * Hematocrit > ~0.55 * Very poor urine output – oliguria or even anuria (<100 mL/day) * Very high white cell count (e.g. >25,000/mL) * Thromboembolism risk / respiratory distress / multisystem compromise (renal, hepatic, pulmonary) * Possibly ARDS (acute respiratory distress syndrome) etc.
Severity
Key Features / Criteria
Mild
- Abdominal bloating - Mild abdominal pain - Ovarian size usually < 8 cm
Moderate
- Moderate abdominal pain - Nausea ± vomiting - Ultrasound evidence of ascites - Ovarian size usually 8–12 cm
Severe
At least one or more of: * Clinical ascites (i.e. fluid visible / detectable) ± hydrothorax * Oliguria: < 300 mL/day or < 30 mL/hour * Haematocrit > 0.45 (i.e. > 45 %) * Hyponatraemia: Na⁺ < 135 mmol/L * Hypo-osmolality: osmolality < 282 mOsm/kg * Hyperkalaemia: K⁺ > 5 mmol/L * Hypoproteinaemia (low albumin) < 35 g/L * Ovarian size usually > 12 cm
Critical
Several of the following life-threatening features: * Tense ascites / large hydrothorax * Haematocrit > 0.55 (i.e. > 55 %) * White cell count > 25,000 /mL * Oliguria / anuria (very low or no urine output) * Thromboembolism risk or actual thrombotic events * Acute respiratory distress syndrome (ARDS) or severe respiratory compromise
150
late vs early OHSS
RCOG also uses the timing relative to the hCG trigger injection to distinguish early vs late OHSS:
* Early OHSS: presents within ~7 days after the hCG trigger injection. Driven mostly by the stimulation protocol. 
* Late OHSS: presents 10 or more days post-hCG trigger (i.e., in the luteal phase or early pregnancy). Driven in large part by endogenous hCG from an early pregnancy. 
(As a note: in some local policies, “late” may be defined slightly differently, e.g. >9 days, but the RCOG text most often uses “10 or more days” as the cutoff. )
151
women with POI are at risk of
osterioperisis
dementia
cardiovascular disease
Parkinsonism
152
if man has CF how to conceive?
using ICSI with sperm retrieval
Also test partner for CF gene
153
what is typical timing of blastocyst transfer
5-6 days in culture
154
when to do USS during IVF
at the start and day 7-9 and 11-14
155
Which technique is suitable for sperm recovery in men with non-obstructive azoospermia?
Testicular sperm extraction (TESE)
156
The proportion of IVF pregnancies resulting in a live birth that are multiple pregnancies
I in 4
157
the prevalence of chlamydia in sub-fertile women in the UK
1-3%
158
what is the specificity of hystero-salpingography in detecting tubal obstruction
0.83
159
what urine output should be prompted medical review in OHSS
less than 1000ml in over 24h
160
161
When to refer for subfertility investigations at less then 2 years of trying
NICE criteria for when to refer / investigate
1. Tried for 1 year without conception
• If a woman of reproductive age has not conceived after 1 year of unprotected vaginal intercourse, she and her partner should be offered a clinical assessment and investigations. 
2. After artificial insemination
• If using artificial insemination (partner or donor sperm) and pregnancy has not occurred after 6 cycles, investigation should be offered. If using partner sperm, assessment includes the partner. 
⸻
When to consider earlier referral (before the 1-year or 6-cycle thresholds)
Referral should be considered sooner if any of the following apply: 
• The woman is aged 36 years or over. Age accelerates decline in fertility. 
• There is a known clinical cause of infertility (for either partner). E.g., history of pelvic inflammatory disease (PID), known tubal disease, previous surgery, etc. 
• A history of predisposing factors for infertility in either partner: examples include amenorrhoea, oligomenorrhoea, undescended testes, etc. 
• If treatment is going to be given that might impair fertility (e.g. cancer treatment), then referral before that treatment. 
162
What is Kallman syndrome
Kallmann syndrome is a genetic condition characterized by:
1. Hypogonadotropic hypogonadism — a failure of the hypothalamus to produce or release enough gonadotropin-releasing hormone (GnRH), leading to low levels of LH and FSH, and consequently low sex steroid hormones (testosterone in males, oestrogen in females).
2. Anosmia or hyposmia — absent or reduced sense of smell.
⸻
🧠 Pathophysiology
• During embryonic development, GnRH-secreting neurons normally migrate from the olfactory placode to the hypothalamus.
• In Kallmann syndrome, this migration fails.
• The olfactory bulbs also fail to develop properly — causing the loss of smell.
• The result: GnRH deficiency, leading to underdeveloped secondary sexual characteristics and infertility.
In males:
• Delayed or absent puberty
• Micropenis, cryptorchidism (in infants)
• Small testes, low libido, infertility
• Lack of secondary sexual characteristics (facial/body hair, voice change, muscle mass)
In females:
• Primary amenorrhoea
• Absent or delayed breast development
• Infertility
Both sexes may have:
• Anosmia or hyposmia (loss/reduction of smell)
• Sometimes associated non-reproductive anomalies:
• Cleft lip/palate
• Hearing loss
• Renal agenesis (especially unilateral)
• Mirror movements (synkinesia)
• Dental agenesis
Investigations
• Hormones:
• Low LH and FSH (hypogonadotropic hypogonadism)
• Low sex steroids (testosterone or oestradiol)
• Olfactory testing: smell test or MRI showing absent/underdeveloped olfactory bulbs
• MRI brain: to exclude pituitary/hypothalamic lesions
• Genetic testing: confirms the diagnosis and inheritance pattern.
⸻
💊 Management
• Hormone replacement therapy for induction and maintenance of secondary sexual characteristics:
• Testosterone in males
• Oestrogen ± progesterone in females
• Gonadotropin therapy (hCG + FSH) or pulsatile GnRH for fertility induction
• Counselling and genetic advice for affected families.
Type
Congenital hypogonadotropic hypogonadism with anosmia
Cause
Defective migration of GnRH and olfactory neurons
Hormones
Low GnRH → low LH/FSH → low sex steroids
Smell
Absent/reduced
Puberty
Delayed/absent
Fertility
Impaired but treatable
Inheritance
X-linked, AD, or AR depending on mutation
163
What is the definition of severe oligospermia and what to do next
<5 million spermatazoa per ml or if azppspermia
Repeat sperm count asap
164
What is the definition of mild and moderate oligospermia
If <15 million spermatozoa but > 5 million spermatozoa per ml
Then repeat in 3 months
165
What is the incidence of 3rd and 4th degree perineal tears during should dystocia SD
3.8%
166
What % of women will labour with in 3 weeks on an IUD
>85%
Monica’s Part 2
flashcards
Decks in class (26)
# Cards
-
Antenatal168
-
Urogynae113
-
Subfertility169
-
Fetal Med133
-
Neonatology26
-
Benigne Gynae.213
-
Sexual Health103
-
Mat Med500
-
Early Pregnancy Care132
-
Oncology138
-
Labour339
-
Postpartum Problems110
-
Research And Teaching80
-
CTG18
-
Vulval CA46
-
Ovarian CA Staging17
-
VTE42
-
Statistics31
-
Endometrial CA staging24
-
Vuvlal CA Staging11
-
Cervical CA Staging22
-
Infections in pregnancy39
-
Menopause5
-
Mat Med 2.0109
-
Thyroid35
-
Breast CA In Pregnancy26
