Shared Flashcard Set

Details

Boards - Infertility
OBGYN Qualifying Exam
211
Other
Post-Graduate
07/11/2020

Additional Other Flashcards

 


 

Cards

Term
diagnostic criteria for RPL
Definition
2+ losses <20 (not counting ectopic, biochemical, molar)
Term
what is a sign in the pregnancy that significantly decreases the risk of loss
Definition
FHR (15 to 3%)
Term
what is the work up for RPL - 7
Definition
cavity assessment (HSC, SIS, HSC, TVUS, MRI), karyotype (maternal, paternal, fetal tissue perferred), TSH, androgens, HBA1C, PRL, luteal length
Term
what are some adjunct labs you could get for RPL if the patient has risks factors or concerning symptoms - 4
Definition
thrombophilia, APAS, infection, autoimmune
Term
risk of pregnancy loss the next pregnancy if you had 3, 4, 5, 6 losses
Definition
3 - 30%
4 - 30%
5 - 40%
6 - 50%
Term
what percent of RPL is due to a genetic condition
Definition
4-8%
Term
what percent of RPL is due to APAS
Definition
10%
Term
what percent of RPL is due to a uterine anomaly
Definition
6%
Term
4 endocrine disorders that cause PRL
Definition
hyperprolactinamia, hypothyroid, diabetes, PCOS
Term
causes of RPL - 13
Definition
age, genetic, uterine anomaly, fibroids, APAS, smoking, alcohol, caffeine, infection, luteal phase deficiency, endocrine, SLE, hyperprolactinemia
Term
why do older women have RPL
Definition
mitotic spindle dysfunction increases the risk of aneuploidy
Term
risk of aneuploidy at 20, 35, 40, 45yo
Definition
20y 1:250, 35y 1:200, 40y 1:65, 45y 1:25
Term
why do older men have a risk of RPL
Definition
increased (slight) aneuploidy of sperm
Term
#1 genetic cause of SAB
Definition
trisomy (#1 being 16)
Term
#1 chromosomal cause of SAB
Definition
turners
Term
#1 chromosomal rearrangement causing SAB
Definition
unbalance reciporical translocation
Term
what is a reciporical translocation
Definition
exchange of arm of nonhomologous chromosome causing balanced (silent) or unbalanced (SAB risk) translocation
Term
what is a robertosonin translocation
Definition
exchange of arm of acrocentric chromosomes (13, 14, 15, 21, 22) causing usually unbalanced translocations which can lead to RPL
Term
what has a higher risk of RPL reciporical or robertosonian translocations
Definition
robertsonian
Term
what are the acrocentric chromosomes
Definition
13, 14, 15, 21, 22
Term
what TSH level is associated with SAB
Definition
TSH >4 or TSH >2.5 with TPO antibodies
Term
goal TSH if has RPL
Definition
<2.5
Term
HBA1C where DM increases SAB
Definition
no increased SAB unless uncontrolled, goal A1C <7
Term
what can decrease SAB in PCOS patients
Definition
metformin
Term
rate of SAB in PCOS
Definition
30-50%
Term
rate of SAB in thrombophilia
Definition
no definitive link to SAB
Term
what is the gold standard, perferred, and other 2 methods for diagnosis of uterine anomalies
Definition
gold standard is LSC, perferred is 3D US less invasive, 2D US has 90% sensitivity, HSG does not see exterior
Term
#1 uterine developmental anomaly
Definition
septum
Term
cause of a uterine septum
Definition
incomplete RESORPTION of the medial septum from paramesonepheric fustion
Term
cause of a unicornuate uterus
Definition
failure of one of the mullerian ducts
Term
cause of bicornuate uterus
Definition
incomplete FUSION of the mullerian ducts
Term
cause of didelphius
Definition
no FUSION of the mullerian ducts
Term
cause of arcuate uterus
Definition
normal varient
Term
which uterine anomalies cause PTD
Definition
unicornuate, bicornuate, didephius?
Term
which uterine anomalies cause SAB and rate
Definition
septate 65%
Term
how can you tell bicornuate and septate apart
Definition
septate will have a convex fundus with a <1cm indent, bucornuate will have 1cm indent
Term
which uteirne anomalies are associated with renal anomalies and what rate
Definition
unicornuate 40%, bicornuate 15%, didelphius ?
Term
risk of uterine anomalies if exposed to DES in utero
Definition
13%
Term
uterine anomalies if exposed to DES in utero - 2
Definition
T uterus, cockscomb cervical hood
Term
which type of fibroid increases SAB
Definition
submucosal, IM insufficient evidence
Term
which uterine anomalies increase the risk of malpresentation
Definition
all of them
Term
what is a luteal phase deficiency
Definition
decreased progesterone from corpus luteum before 7wk gestation when the placenta takes over
Term
how is luteal phase deficiency diagnosed - 2
Definition
it isnt, there is no good test. luteal phase <13d, EMBX path >2d from menstural dating
Term
if you suspect a luteal phase deficiency what do you need to rule out
Definition
thyroid and prolactin disorders, both shorten the luteal phase
Term
management of luteal phase deficiency
Definition
progesterone does not help, nothing to do
Term
% of reporductive age women with APAS
Definition
5
Term
% of SLE patients with APAS
Definition
37%
Term
diagnosis of APAS - clinical
Definition
VTE, 3+ SAB <10wk, 1+ loss >10wk, PTD <34w with placental insufficiency or pre-e
Term
diagnosis of APAS - lab
Definition
antiphospholipid Ab, B2 microglobulin, anticardipin Ab (2x >12wk apart, IgG/M)
Term
why does APAS cause RPL and VTE
Definition
antibiodies to maternal and trophoblast vessel endothelium, antibodies to trophoblast itself
Term
complications of APAS clinically - 7
Definition
VTE, IUGR, pre-e, RPL, stillbirth, amaurosis fugax, alloimmune thrombocytopenia (50%)
Term
infection that is associated with RPL
Definition
BV
Term
possible infections potentially associated with RPL - 4
Definition
ureaplasma, mycoplasma, toxoplasma, listeria
Term
effects of smoking on fertility -
Definition
increases time to conception, increases SAB, early menopause due to follicle toxicity
Term
alcohol level that would contribute to RPL
Definition
>2 drinks/d
Term
caffeine level that would contribute to RPL
Definition
>300mg/d
Term
APAS DVT prevention - pregnant and history of VTE
Definition
heparin
Term
APAS DVT prevention - has RPL
Definition
heparin and ASA
Term
APAS DVT prevention - pregnant and no history of VTE
Definition
heparin
Term
contraception ok in APAS
Definition
anything without estrogen
Term
% of couples infertile
Definition
15
Term
% of infertility that is female, male, both, unexplained
Definition
female 40%, male 30%, both 10%, unexplained 20%
Term
% of infertile patients with depression
Definition
37%, 19% severe
Term
% of depression after failed IVF
Definition
43%
Term
define fertility
Definition
the ability to achieve a clinically recognized pregnancy
Term
define fecuntability
Definition
probability per menstural cycle of achieving a pregnancy
Term
define fecundidity
Definition
ability of a couple to achieve a live birth
Term
define infertility
Definition
>1y without contraception and regular intercourse without pregnancy, >6mo if 35yo+
Term
% that will conceive in 3, 6, 12, 24mo
Definition
3 - 57%, 6 - 72%, 12 - 85%, 24 - 93%
Term
indications to refer to REI - 6
Definition
>40yo, >35yo, oligomenorrhea, suspected uterine/tubal disease, stage 3-4 endo, suspected male factor
Term
after the LH surge how long until an egg is released
Definition
36-48h, 24h from the peak
Term
how long can an egg live
Definition
12-24h
Term
how long can a sperm live
Definition
5d
Term
what is the window of fertility
Definition
the 72h before ovulation is highest rates
Term
how can you evaluate ovarian reserve - 4
Definition
AFC, CD4 FSH/E2/inhibin B, clomiphine challenge, antimullerian hormone
Term
ways to evaluate if someone is ovulating
Definition
D1 progesterone >3 (if not repeat it because they could have long cycles)
Term
what do you need to evaluate in infertility - 7
Definition
if their ovulating, ovarian reserve, tubes, uterus, TSH, HBA1C, prenatal labs
Term
what are some labs you can consider in an infertility work up if the patient meets criteria - 4
Definition
thrombophilia, karyotype (abn SA, POF), EMBX if AUB and qualifies, PRL if AUB
Term
what is a normal CD4 FSH, E3, inhibin B, is elevation or decrease indication of decreased ovarian reserve
Definition
FSH <10 (increased means less follicles), E2 <60 (increased means there is advanced follicle recruitment in old ovaries), inhibin B should be elevated (if decreased less ability to concieve, non specific)
Term
how does a clomiphine challenge work
Definition
CD3 FSH/E2 -> CD 5-9 100mg colmiphine -> CD10 FSH/E2
Term
how is a clomiphine challenge inerperted
Definition
FSH <10 and lower E2 is normal, increased FSH means less follicles
Term
what is a normal AMH
Definition
<1.5 ng/dL
Term
what can increase AMH
Definition
PCOS
Term
what does AMH do
Definition
made in granulosa cells, recruitment (transitions resting follicles into growing follicles)
Term
what are 3 ways to monitor if someone is ovulating
Definition
basal body temp, serum LH, urine LH, cervical mucous
Term
what is the best monitoring for ovulation
Definition
serum LH, 1st day of surge will be mid cycle
Term
what is the worst way to monitor if someone is ovulating
Definition
basal body temp, its too late, it rises after ovulation and there isnt enough to sex before the egg dies
Term
how effective is urine LH at monitoring for ovulation
Definition
less than serum LH but also indicates mid ovulation
Term
what can falsley elevate urine LH - 2
Definition
PCOS, perimenopause
Term
how do you use cervical mucous to monitor ovulation
Definition
peaks 2-3d before ovulation
Term
why cant you use progestetrone to monitor for ovulation
Definition
it peaks after ovulation, too late
Term
5 values indicating decreased ovarian reserve
Definition
AMH <1, FSH >10 CD3, E2 >60 CD3, AFC <5-7, <4 oocytes retreived
Term
what does decreased ovarian reserve say about the ability to concieve, risk of SAB, and overall fertility
Definition
it doesnt say anything about any of these things, only the response they will have to stimulation
Term
7 causes of decreased ovarian reserve
Definition
fragile X, PCOS, turners, chemo/RT, ovarian surgery, kallmans, hyperprolactin
Term
the 5 factors to consider as causes for infertility
Definition
ovarian reserve, tubal, uterine, endometriosis, unexplained
Term
% of infertility that is tubal factor
Definition
25-35%
Term
#1 cause of tubal factor infertility
Definition
salpingitis 50%
Term
% that recall having PID and % that have chlamydia Ab and clinical signs of PID
Definition
31% recall it, 79% had it
Term
what is a way you can avoid LSC/chromo if someone has a HSG with no flow and it could be tubal spasm
Definition
if they have negative chlamydia antibodies you can consider skipping and assume it was spasm
Term
salpingitis accounts for % of ectopic pregnancies
Definition
50
Term
risk of ectopic in salpingitis
Definition
8%
Term
risk of tubal infertility after 1, 2, 3 pelvic infections
Definition
1 - 10%, 2 - 30%, 3 - 75%
Term
causes of tubal factor infertility - 4
Definition
salpingitis, tubal fibrosis/endometriosis, essure/tubal, salpingitis isthmica nodosa, hydrosalpinx
Term
hydrosalpinx decreases pregnancy by %
Definition
50
Term
what is the recommendation for infertility treatment if salpingitis isthmica nodosa is diagnosed
Definition
IVF is recommended, high risk of ectopic
Term
what is salpingitis isthmica nodosa
Definition
diverticula of the mucosa into the mesosalpinx
Term
what is the recommended fertility treatment for tubal fibrosis/endometriosis
Definition
could try micro surgical excision/repeair
Term
what is the recommended fertility treatment if someone has essure
Definition
IVF
Term
can essure coils poke the baby
Definition
25% are encapsulated, donno
Term
what is the fecundity rate of unexplained infertility
Definition
1.8-3.8% depending on age and length of infertility
Term
why does endometriosis cause infertility - 4
Definition
inflammation (increased IL1, IL6, NK), decreased tubal transport
Term
4 types of male infertility and their prevalence
Definition
idiopathic 40%, pre-testicular 1%, testicular 40%, post-testicular 20%
Term
management of idiopathic male infertility
Definition
clomiphine
Term
how does clomiphine help with male infertility - 3
Definition
increases rate of pregnancy, sperm concentration, sperm motility
Term
what phsyiologic process causes pre-testicular male infertility
Definition
hypogonadotrophic hypogonadism
Term
causes of male hypogonadotrophic hypogonadism - 6
Definition
kallmans, steroids, testosterone replacement, obesity, hyperprolactinemia, brain mass
Term
what brain masses can cause male hypogonadotrophic hypogonadism - 4
Definition
harmatoma, craniopharyngoma, lymphoma, pituitary tumor
Term
why does hyperprolactinemia cause male hypogonadotrophic hypogonadism
Definition
PRL inhibits LH which decreases testosterone which makes less sperm
Term
signs of male hyperprolactinemia - 5
Definition
ED 99%, decreased libido 88%, decreased body hair 40%, gynecomastic 21%, galactorrhea 13%
Term
causes of male hyperprolactinemia - 2
Definition
pituitary tumor, drug induced
Term
treatment of male hyperprolactinemia - 2
Definition
dopamine agonists, testosterone for libido only does not help fertility
Term
causes of testicular male infertility - 4
Definition
karyotype abnormalities, chemo/RT, trauma/torsion, varicocele
Term
2 karyotype abnormalities causing male infertility
Definition
kleinfelters syndrome, Y chromosome AZF deletion
Term
what % of men with sex chromosome aneuploidy and infertility have kleinfelters
Definition
2/3
Term
how is kleinfelters inherited
Definition
can pass to male offspring
Term
how is AZF deletion diagnosed
Definition
testicular biopsy
Term
how is AZF deletion sometimes identified
Definition
cant get sperm for ICSI
Term
3 types of AZF deletion and their sperm prognosis
Definition
A - proximal - azospermia
B - central - azospermia
C - distal - oligospermia
Term
which AZF deletion is inherited
Definition
C is always passed to any son
Term
management of infertility if AZF deletion
Definition
AZFc - try testicular extraction
AZFa-b - sperm donor
Term
cause of varicocele
Definition
dilated panpiniform plexus
Term
incidence of varicocele
Definition
20% of men
Term
varicocele accounts for __% of primary and __% of secondary male infertility
Definition
40% primary, 80% secondary
Term
how is infertility managed with varicocele
Definition
surgical treatment improves fertility
Term
how are varicoceles graded
Definition
1 - only seen with valsalva
2 - palpable without valsalva
3 - visible when standing
Term
5 causes of post-testicular infertility
Definition
absent vas deferens, epididymal obstruction, ejaculatory duct obstruction, erectile dysfunction, ejaculatory dysfunction
Term
4 types of ejaculatory dysfunction
Definition
premature, delayed, anorgasmia, retrograde
Term
what is retrograde ejaculation
Definition
sperm reflux into the bladder and are affected by the acidic urine
Term
3 causes of retrograde ejaculation
Definition
MS, DM neuropathy, cord injury
Term
how is retrograde ejaculation diagnosed- 2
Definition
ejaculate with urine in it, decreased semen <1mL
Term
how is retrograde ejaculation treated - 2
Definition
antihistamines/ephedrine to close the bladder neck, IUI is best for infertility
Term
define azospermia
Definition
no sperm in 2 samples
Term
what other lab value should be abnormal in azospermia
Definition
no fructose
Term
testing that needs to be done if azospermia - 5
Definition
Y chromosome for AZF, CF, testosterone, FSH, HPA imaging if hypogonadotrophic hypogonadism
Term
AZF is __% of men with azospermia
Definition
15%
Term
2 types of tubal microsurgery repair
Definition
HSC catheterization, microsurgical resection
Term
method of tubal ligation BTA success in order
Definition
clips > bands > pomeroy > cauterization
Term
length a tube must be for BTA
Definition
4cm
Term
area of tube where ligation occured BTA success in order
Definition
ischmic > ampullary
Term
# factor in success of BTA
Definition
age
Term
success rate of BTA
Definition
50-80% (50% is 45yo)
Term
#1 infertility med for unexplained infertility
Definition
clomiphine
Term
#1 infertility med for PCOS, why -2
Definition
letrazone - increases ovulation, increases live birth rate
Term
infertility med for hypogonadotrophic patients
Definition
gonadotrophins
Term
infertility meds for non hypogognadotrophic patients
Definition
letrazone, clomid
Term
MOA clomid
Definition
E2 antagonist, decreases E2 feedback which increases GNRH and thus FSH which causes follicle development
Term
dose clomid
Definition
50mg/d CD 5-9 can increase up to 200mg
Term
SE clomid - 5
Definition
multiples, hot flashes, headache, irritability, visual changes
Term
rate of multiples clomid
Definition
twins 8%, triplets 0.3%
Term
efficacy of clomid
Definition
85% respond
Term
MOA letrazone
Definition
aromatase inhibitor decreases testosterone which decreases estrogen, lack of estrogen negative feedback causes increased GNRH and thus FSH which causes follicle development
Term
dosing of letrazole
Definition
2.5-5mg/d CD 3-7
Term
side effects letrazole - 9
Definition
headache, hot flashes, mood swings, night sweats, osteoporosis, nausea, constipation, dizziness, fatigue
Term
contraindications to clomid - 3
Definition
breast feeding, pregnancy, <18yo
Term
what are gonadotropins (the med)
Definition
FSH +/- LH
Term
SE gonadotropins
Definition
OHSS
Term
indications for gonadotropins - 3
Definition
hypogonadotrophic hypogonadism, PCOS, failed others 3-6C
Term
rate of OHSS in infertility tx
Definition
5-8%
Term
physiology of OHSS
Definition
increased hCG causes increased VEGF which causes vascular permability which causes extravascular fluid, hemoconcentration, and decreased end organ perfusion, all of this can cause VTE too
Term
labs for mild OHSS
Definition
normal
Term
labs for moderate OHSS - 2
Definition
HCT >41%, WBC >15
Term
labs for severe OHSS - 7
Definition
HCT >51%, WBC >25, elevated LFT, CrCl <50, Cr >1.6, Na <135
Term
signs of mild OHSS - 5
Definition
abdominal pain, distention, nausea, vomiting, diarrhea
Term
signs of moderate OHSS - 2
Definition
mild plus ascites on US
Term
signs of severe OHSS - 9
Definition
clinical ascites, hydrothorax, dyspnea, oliguira, intractable N/V, hypotension, rapid weight gain, syncope, severe pain
Term
signs of critical OHSS - 6
Definition
aneuria, arrhythmia, VTE, pericardical effusions, hydrothorax, ARDS
Term
rate of critical OHSS
Definition
1.4% of OHSS
Term
risk in OHSS at all stages
Definition
torsion (high in ART, higher in OHSS)
Term
treatment of OHSS - 2
Definition
supportive, cabergoline to reverse VEGF
Term
prevention of OHSS - 3
Definition
cancel cycle and withold gonadotrophins when indicated, freeze embryos, cabergoline PPX
Term
treatment of unexplained infertility
Definition
patient is ovulating on their own so OI/TI wont work, IUI alone was tried and it didnt work, best is OI/IUI, als decreased smoking, BMI, caffeine
Term
fecundity with OI/IUI in unexplained infertility
Definition
9.5%
Term
5 steps of IVF
Definition
1 - hCG 10d
2 - egg retrevial 30-36h post trigger shot
3 - progesterone for luteal support
4 - embryo transfer
5 - 10-11d take a pregnancy test
Term
indications for ISCI - 6
Definition
male factor infertility, PGD, in vitro matured eggs, prior frozen eggs, surgical retrevied sperm
Term
complication of ISCI - 2
Definition
imprinting disorders - beckwith-weidman, angelman
Term
rate of beckwith weidman with ISCI
Definition
1:2700
Term
cause of becjwith weidman
Definition
increased with ISCI, CH 11 methylation error
Term
signs of beckwith weidman - 4
Definition
macrosomia, microglossia, midline abdominal defects, embryonal carcinoma risk
Term
complications of IVF - 5
Definition
multiples 30x, monozygotic twins increased, cardiac defects 1 to 3% (ASD/VSD most common), imprinting disorders, sex chromosome disorders
Term
success rate of IVF
Definition
<35yo 50%, >42yo 5%
Term
4 types of sample collection for PGT
Definition
polar body, blastomere, blastocyst trophectoderm, FISH
Term
what is the best sample collection for PGT
Definition
blastocyst trophectoderm, 100s of cells
Term
why is blastomere sampling not the best collection for PGT
Definition
only samples one cell may not represent
Term
what is FISH PGT and its accuracy
Definition
specific chromosome probes, 60% accurate and does not improve live birth rate
Term
3 testing types of PGT
Definition
PGT-M monogenic - single gene disorders
PGT-SE - structiral rerangements (translocations, imprinting, disomy)
PGT-A aneuploidy - whole chromosome abnormalities
Term
how many times can someone donate sperm or eggs
Definition
25 pregnancies allowed per donor per population of 800,000
Term
requirements for a sperm donor - 8
Definition
17yo min ideally <40yo, psych assessment, determined rights/legal if known donor, full history, quarentine 6mo if annomynouos, negative STI testing, common mutation screening, education on FHX specific mutation screening
Term
if a sperm donor is educated on FHX specific mutation screening and declines what does the reciever of the sperm get to know
Definition
that that have a FHX increased risk of mutations and declined genetic testing
Term
complications of oocyte retrevial - 5
Definition
inicreased ovarian cancer if >12C, anesthesia complications, surgical complications, PID, OHSS
Term
6 forms of fertility preservation
Definition
oocyte cryopreservation, embryo cryopreservation, ovarian transplant, in-vitro maturation (experimental), ovarian tissue freezing (experimental), GNRH suppression
Term
which is better oocyte or embryo cryopreservation and why
Definition
embryo, oocytes have higher cytoplasm and dont thaw as well causing decreased implantation and pregnancy, improvements in slow thaw, virification, and cryoprotectant have improved it to almost the same as embryo though
Term
what is an ovarian transplant
Definition
moving ovary out of a radiotherapy field in cancer patient
Term
what is in-vitro maturation
Definition
experimental, taking oocytes without stimulation to use after cancer treatment
Term
what is ovarian tissue freezing
Definition
freezing part of the ovary and putting it back after cancer treatment
Term
what is the concern for ovarian tissue freezing
Definition
re-introducing cancer
Term
how well does GNRH suppression work for protecting the ovaries during cancer treatments
Definition
not very well, not increasing pregnancy rates, protects oocytes in pre-puberty better though
Term
4 types of stem cells which are promising for making embryos
Definition
hematopoetic/marrow strong bias not promising, embryonic (3 gem layers) promising, embryonal cancer (zygotes arrest) not promising, pluoripotent stem cells most promising
Term
etihical issues with embryonic stem cells
Definition
not their biologic offspring, embryo could parent multiple offspring
Term
concerns with embryonal stem cells
Definition
arrest at 6-8 cells likley due to imprinting, cancer so could have mutations
Term
concerns for pluoripotent stem cells
Definition
oncogenic viral vectors
Term
how do pruoripotent stem cells work
Definition
retroviral introduction into genes of somatic cells
Supporting users have an ad free experience!