Gynaecology Pg No 195 -204 (Infertility&Contraception)
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Questions and Answers

What is the mechanism of action for the DMPA injection used in contraception?

  • Thickening of cervical mucus
  • Inhibition of tubal motility
  • Anovulation (correct)
  • Prevent fertilization

    • Increased seizure frequency may occur when using OCPs in a patient taking lamotrigine.

    True

    What are the two permanent contraception methods listed?

    Tubal ligation and vasectomy

    The primary action of the Copper IUD is to prevent __________.

    <p>fertilization</p> Signup and view all the answers

    Match the contraceptive methods with their primary mechanisms:

    <p>DMPA = Anovulation Copper IUD = Prevention of fertilization Progesterone implant = Prevention of implantation Mirena = Inhibition of implantation</p> Signup and view all the answers

    What is a prerequisite for intrauterine insemination (IUI)?

    <p>Sperm concentration: 10 million/ml</p> Signup and view all the answers

    Cystic fibrosis can cause the absence of the vas deferens and seminal vesicle.

    <p>True</p> Signup and view all the answers

    What is the best processing technique for semen used in IUI?

    <p>Glasswool filtration technique</p> Signup and view all the answers

    In the diagnostic flow chart for obstructive azoospermia, if the semen volume is normal and fructose is present, it indicates a _____ of seminal vesicle to semen.

    <p>contribution</p> Signup and view all the answers

    Which of the following conditions indicates infertility issues in males?

    <p>Hypospadias</p> Signup and view all the answers

    Match the following treatment procedures with their descriptions:

    <p>IUI-H = Semen obtained from the husband IUI-D = Semen obtained from donor Swim up technique = Separates motile sperm from other components Density centrifugation technique = Uses density gradients to isolate sperm</p> Signup and view all the answers

    Assisted Reproductive Techniques include IUI.

    <p>False</p> Signup and view all the answers

    What is the minimum sperm count required for In Vitro Fertilization (IVF)?

    <p>5 million/mL</p> Signup and view all the answers

    IVF includes fertilization followed by __________ of the embryo on day 3 or 5.

    <p>embryo transfer</p> Signup and view all the answers

    Match the following assisted reproductive techniques with their descriptions:

    <p>IVF = In vitro fertilization where eggs and sperm are combined outside the body ICSI = Intracytoplasmic sperm injection for severe male factor infertility GIFT = Gamete intrafallopian transfer, placing eggs and sperm in the fallopian tubes ZIFT = Zygote intrafallopian transfer, placing a fertilized egg in the fallopian tubes</p> Signup and view all the answers

    Which of the following organs is primarily responsible for the production of sperm?

    <p>Testis</p> Signup and view all the answers

    The prostate gland plays a role in the liquefaction of semen.

    <p>True</p> Signup and view all the answers

    Name one possible cause of hypogonadotropic hypogonadism.

    <p>Kallman syndrome</p> Signup and view all the answers

    Azoospermia can be diagnosed after a minimum of _____ days following the first semen analysis.

    <p>7</p> Signup and view all the answers

    Match the following conditions with their corresponding testosterone and FSH levels:

    <p>Klinefelter syndrome = ↑ FSH &amp; Testosterone Obstructive Azoospermia = Normal FSH &amp; Testosterone Hypogonadotropic hypogonadism = ↓ Testosterone Heat exposure (miners) = ↑ FSH &amp; Testosterone</p> Signup and view all the answers

    What is the drug used for ovulation triggering in female ovarian stimulation?

    <p>Inj. hCG</p> Signup and view all the answers

    The success rate of IVF is 50-60%.

    <p>False</p> Signup and view all the answers

    What is the primary method of monitoring follicles during ovarian stimulation?

    <p>Transvaginal ultrasound (TVS)</p> Signup and view all the answers

    The __________ stage of embryo transfer occurs on day 5.

    <p>blastocyst</p> Signup and view all the answers

    Match the following infertility causes with their descriptions:

    <p>Oligospermia = Low sperm count (5-10 million/mL) Azoospermia = Absence of sperm in semen Endometriosis = Severe condition affecting reproductive organs Müllerian agenesis = Congenital absence of uterus</p> Signup and view all the answers

    What is the most common cause of male infertility?

    <p>Abnormal spermatogenesis due to testicular causes</p> Signup and view all the answers

    Fecundability is the probability of having a live birth in one cycle.

    <p>False</p> Signup and view all the answers

    What is the definition of primary infertility?

    <p>Female has never conceived.</p> Signup and view all the answers

    In males, the most common reversible cause of infertility is __________.

    <p>Varicocele</p> Signup and view all the answers

    Match the following tests with their purpose:

    <p>Semen analysis = Evaluating sperm parameters S. Progesterone test = Testing for ovulation HSG = Checking for tubal patency Serum AMH = Assessing ovarian reserve</p> Signup and view all the answers

    What is the minimum volume of semen considered to avoid aspermia?

    <p>1.4 mL</p> Signup and view all the answers

    The sample for semen analysis should be collected in a latex condom.

    <p>False</p> Signup and view all the answers

    What condition is indicated by a sperm motility of less than 5%?

    <p>Asthenospermia</p> Signup and view all the answers

    What is the recommended liquefaction time for semen analysis?

    <p>20 to 30 minutes</p> Signup and view all the answers

    ICSI involves injecting multiple sperm into the egg.

    <p>False</p> Signup and view all the answers

    Azoospermia is defined as the presence of ________ in semen.

    <p>no sperms</p> Signup and view all the answers

    Name one surgical method used to retrieve sperm.

    <p>TESA, TESE, PESA, or MESA</p> Signup and view all the answers

    Match the following parameters with their corresponding minimum cut-off values:

    <p>Volume = 1.4 mL Concentration = 16 million/mL Morphology = 4% Motility = 42%</p> Signup and view all the answers

    ICSI may be indicated for severe oligospermia, defined as less than __________ sperm/mL.

    <p>5 million</p> Signup and view all the answers

    Match the following male infertility conditions with their sperm count ranges:

    <p>Oligospermia = 10-15 million/mL Severe Oligospermia = Less than 5 million/mL Subclinical Oligospermia = 5-10 million/mL Azoospermia = 0 million/mL</p> Signup and view all the answers

    Which of the following is considered a high dose of estrogen in OCPs?

    <p>50 mcg</p> Signup and view all the answers

    A history of breast cancer is an absolute contraindication for the use of OCPs.

    <p>True</p> Signup and view all the answers

    Name one type of 4th generation progesterone used in OCPs.

    <p>Norgestimate</p> Signup and view all the answers

    The minimum effective dose of estrogen in OCPs is __________ mcg.

    <p>10</p> Signup and view all the answers

    Match the following contraceptive classifications with their categories:

    <p>High dose = Ethinyl estradiol ≥ 50 mcg Low dose = Ethinyl estradiol &lt; 50 mcg Very low dose = Ethinyl estradiol &lt; 20 mcg Minimum possible dose = 10 mcg</p> Signup and view all the answers

    Which of the following is NOT a common cause of asthenospermia?

    <p>Klinefelter syndrome</p> Signup and view all the answers

    Klinefelter syndrome is characterized by 47XXY chromosomes.

    <p>True</p> Signup and view all the answers

    What is the primary function of the Prader orchidometer?

    <p>Measuring testis size</p> Signup and view all the answers

    Spermatogenesis begins at __________.

    <p>puberty</p> Signup and view all the answers

    Which hormone is responsible for stimulating Sertoli cells in spermatogenesis?

    <p>Follicle Stimulating Hormone (FSH)</p> Signup and view all the answers

    Match the following conditions with their corresponding characteristics:

    <p>Kartagener syndrome = Immotile cilia Klinefelter syndrome = 47XXY Asthenospermia = Reduced sperm motility Varicocele = Enlargement of veins in the scrotum</p> Signup and view all the answers

    Which condition is characterized by tall stature, gynecomastia, and hyposplastic testicles?

    <p>Klinefelter syndrome</p> Signup and view all the answers

    Obstructions in sperm passage can contribute to infertility in males.

    <p>True</p> Signup and view all the answers

    Study Notes

    Oral Contraceptives

    • POP (LNG): Thickens cervical mucus, thins endometrium, and inhibits tubal motility
    • Progesterone implant/injection/cerazette (desogestrel): Causes anovulation, prevents fertilization, and hinders implantation
    • Cu IUD: Prevents fertilization, induces an inflammatory reaction, and inhibits implantation
    • MIRENA: Inhibits implantation by making the endometrium out of phase
    • Centchroman (Chaya): Mechanism of action unspecified

    Long-acting reversible contraceptives (LARC)

    • DMPA Injection: Also known as Antara, contains depot medroxyprogesterone acetate, administered intramuscularly every 3 months, 150mg dose
    • IUD: A type of long-acting reversible contraceptive, can be Copper IUD or MIRENA

    Permanent methods

    • Tubal ligation
    • Vasectomy

    Epilepsy and Contraception

    • Not on antiepileptic medications: Any contraceptive can be used including OCPs
    • On antiepileptic medication: Use progesterone-only contraceptives; OCPs decrease lamotrigine efficacy and increase the risk of seizures

    Mechanism of Action (DMPA Injection)

    • Anovulation

    Advantages of DMPA Injection

    • ↓ Seizure frequency in epileptics
    • ↓ Sickling in sickle cell anemia

    Disadvantages of DMPA Injection

    • Delayed return of fertility (2-18 months)
    • ↓ Bone mineral density
    • Irregular bleeding (most common reason for discontinuation)

    Obstructive Azoospermia - Diagnostic Flow Chart

    • Low semen volume, ↓ fructose: Indicates no contribution from the seminal vesicle.
    • Normal semen volume, fructose +: Indicates contribution of the seminal vesicle to semen.
    • Block above seminal vesicles: Suspect vas deferens, epididymis.
    • Normal scrotal ultrasound: Suggests retrograde ejaculation.
    • Not seen on scrotal ultrasound: Suspect cystic fibrosis (absence of vas deferens & seminal vesicle).
    • Confirmation of cystic fibrosis: CFTR gene mutation.
    • Dilated Ejaculatory duct obstruction: Possible cause of obstruction.

    Intauretine Insemination (IUI)

    • Injecting sperm into the uterus.
    • Prerequisite: Sperm concentration of 10 million/ml and 14% sperm morphology.
    • Processing of semen: Swim up, swim down, density centrifugation, and glasswool filtration techniques used; glasswool filtration preferred.
    • Procedure: 0.5 mL of concentrated processed sperm injected into the uterus using an IUI catheter, bypassing the cervix, enabling sperm travel to the fallopian tube.

    Obtaining Semen for IUI

    • IUI-H: Sperm from husband
    • IUI-D: Sperm from donor

    Active Space in Infertility Treatment

    • Performed in: Cervix abnormalities, ejaculatory abnormalities
    • Not performed in: Females with tubal blockage

    Assisted Reproductive Techniques

    • Includes: IVF, ICSI, GIFT, ZIFT
    • Excludes: IUI

    Indications for IUI

    • Oligospermia: 10-16 million/mL
    • Ejaculatory causes: Hypospadias, retrograde ejaculation
    • Vaginismus: Involuntary vaginal muscle contraction
    • Other Indications: Discordant HIV status in partners, anti-sperm antibodies in the cervix, mild endometriosis, and unexplained infertility

    Note Regarding IUI

    • Performed at the time of ovulation.
    • HCG test is done before IUI to rule out tubal blockage.

    In Vitro Fertilization (IVF)

    • Pre-requisite: Sperm count of 5 million/mL

    Procedure for IVF

    • Female: Ovary stimulation, follicular monitoring using transvaginal sonography (TVS), trigger ovulation when follicles > 17mm, oocyte pickup the same day under ultrasound guidance.
    • Male: Semen sample collected on the day of oocyte pickup, semen processing.
    • Incubation, fertilization, and Embryo transfer (Day 3 or 5): Embryo transfer occurs two to three days after fertilization.

    Note on IVF

    • Fertilization occurs in an incubator in a Petri dish.
    • Progesterone is given before embryo transfer to prepare the endometrium for implantation.
    • Pre-implantation genetic testing can be performed on day 3 or 5 embryos.
    • Cryopreservation can be done for secondary oocytes.

    Indications for IVF

    • Oligospermia: 5-10 million/mL
    • Tubal cause of infertility
    • IVF with donor eggs in premature ovarian insufficiency
    • IVF with surrogacy in müllerian agenesis
    • Severe endometriosis
    • Pre-implantation genetic testing

    Not used in IVF

    • Severe oligospermia
    • Azoospermia
    • Asthenospermia

    Male Infertility

    • Definition: Inability to conceive after 1 year of unprotected intercourse.

    Age of Infertility Investigation

    • Female Age | Period of Unprotected Intercourse
    • 45 yrs | 3 months

    Causes of Infertility

    • Female Factors: 40-35%
    • Male Factor Contribution: 40%
    • Male Factors Alone: 20%
    • Unexplained: 10%

    Investigations for Infertility

    • Basic Investigations:
      • Semen analysis
      • Test for ovulation: S.Progesterone levels on day 22 of the cycle (if normal)
      • Test for tubal patency: HSG between days 7 and 10
      • For female partner ≥35 years: Test for ovarian reserve (Serum AMH)

    Types of Infertility

    • 1° infertility: Female has never conceived.
    • 2° infertility: Female has conceived previously (irrespective of outcome) but is currently unable to conceive.

    Fecundability and Fecundity

    • Fecundability: Probability of conceiving in one cycle.
    • Fecundity: Probability of having a live birth in one cycle.

    Common Causes of Infertility

    • Most common cause: Abnormal spermatogenesis due to testicular causes, leading to gonadal failure (e.g., Klinefelter syndrome)
    • Most common reversible cause: Varicocele

    Note on Male Infertility

    • ↑ Paternal age → ↑ risk of structural & chromosomal defects in sperm.
    • Quality of sperm monitoring: Sperm DNA fragmentation test (done before IVF).

    Semen Analysis

    • Performed after 3 days of abstinence (3-7 days).
    • < 2 days: False low sperm concentration.

    • 7 days: False high dead sperm concentration.

    • Sample should reach the lab within 1 hour.
    • Analysis is done on liquefied semen.
    • Liquefaction time: 20 to 30 minutes.
    • Sample collection: Via masturbation into a sterile container.
    • Not collected in a latex condom.
    • Maturity & motility of sperms:
      • Maturity: Proximal end of epididymis.
      • Motility: Distal end of epididymis.

    WHO 2022 Semen Analysis Parameters

    • Features | Minimum cut off | Conditions
    • Volume | 1.4 mL | Aspermia: Absence of semen
    • pH | 7.2 |
    • Concentration | 16 million/mL | Oligospermia: < 16 million/mL, Severe oligospermia: < 5 million/mL, Azoospermia: No sperms
    • Morphology | 4% as per Strict Tygerberg criteria | Teratozoospermia: ↑ in abnormal sperms
    • Motility | Total motility: 42%, Progressive motility: 30% | Asthenospermia: ↓ Sperm motility
    • Viability | 54% | Necrozoospermia: ↑ in no. of non viable sperms
    • Total sperm count | 39 million/ejaculate |

    Important Parameters for Semen Analysis

    • Morphology > motility > concentration.
    • Sperm parameters constant from 2010 to 2022:
      • Sperm morphology
      • Total sperm count

    Common causes** of azoospermia:**

    • Klinefelter syndrome: 47XXY
    • Cystic fibrosis
    • Congenital bilateral absence of vas deferens & seminal vesicles
    • CFTR gene mutation

    Classification of OCPs based on Estrogen Dose

    • High dose: Ethinyl estradiol ≥ 50 mcg
    • Low dose: EE < 50 mcg (e.g., 30 mcg)
    • Very low dose: EE < 20 mcg
    • Minimum possible dose: 10 mcg

    Classification of OCPs based on Progesterone

    • 1st generation: Norethindrone
    • 2nd generation: LNG
    • 3rd generation: Desogestrel (Least androgenic side effects)
    • 4th generation: Norgestimate, Gestodene, Drospirenone
    • Antiandrogenic
    • Antimineralocorticoid: → weight loss
    • ↑ K+

    Absolute Contraindications of OCPs

    • Mnemonic: "Banks have various schemes to provide home loans during May."
    • History of breast cancer
    • **Severe uncontrolled hypertension (WHO: ≥160/100 mmHg; CDC: ≥140/90 mmHg)
    • **History of venous/arterial thrombosis, MI, CAD, stroke/lupus anticoagulant antibody (+)
    • Smokers ≥ 35 years of age
    • Pregnant; history of peripartum cardiomyopathy.

    Female Ovarian Stimulation

    • Controlled ovarian hyperstimulation: Success rate of IVF: 20-30%
    • Hyperstimulation: Can lead to multiple oocytes.
    • Drug used: HMG/GnRH analogue
    • Monitoring: Follicles on TVS (Numbers, size)
    • Ovulation Trigger: Done when ≥ 2 follicles with ≥ 17mm.
    • Drug used: Inj.hCG
    • Ovulation occurs: 24-36 hrs after Inj hCG
    • Oocyte Retrieval: Done under US guidance in OT, under anesthesia.
    • Fertilization: On the same day as retrieval.
      • Culture media: Semen + oocyte added. Rich in pyruvate.
      • 50,000 - 100,000 sperms per oocyte.
    • Embryo Transfer:
      • Day 3: Cleavage stage.
      • Day 5: Blastocyst stage (better).
      • Site: 2 cm below uterine fundus.
      • Instrument: Cook's catheter.
    • Note: Fertilization occurs in an incubator, in a petri dish.
    • Progesterone given prior to embryo transfer: Prepares the endometrium for implantation.
    • Pre-implant genetic testing: Done on day 3/5 embryo. No abnormality -> Implemented.
    • Cryopreservation: Can be done for secondary oocytes.
    • Success rate: 20-30% - ↑ed by multiple embryo transfer.

    Levels of Organs Involved in Spermatogenesis

    • Pre-testicular organs: Hypothalamus & pituitary
    • Testicular organs: Testis
    • Post-testicular organs: Seminal vesicles, Epididymis, Ejaculatory duct, vas deferens (not necessary for spermatogenesis, necessary for sperm passage)

    Semen

    • Seminal vesicle: Contributes to semen
    • Prostate gland: Secretes prostatic enzymes → Liquefaction of semen.
    • Bulbourethral gland: Secretes fluids during intercourse.

    Prader orchidometer

    • Used for measuring testis size.

    Spermatogenesis

    • Begins at puberty.

    Defects and Obstructions in Spermatogenesis

    • Defects in spermatogenesis.
    • Obstructions in sperm passage.

    IntraCytoplasmic Sperm Injection (ICSI)

    • Procedure: Collect egg and sperm samples, similar to IVF. Inject a single sperm into the cytoplasm of a single egg.

    Indications for ICSI

    • Severe oligospermia: Less than 5 million sperm/mL.
    • Azoospermia.
    • Asthenospermia: Sperm motility less than 5%.

    Surgical Methods to Retrieve Sperms:

    • TESA: Testicular Sperm Aspiration
    • TESE: Testicular Sperm Extraction
    • PESA: Percutaneous Epididymal Sperm Aspiration
    • MESA: Microsurgical Epididymal Sperm Aspiration

    Male Infertility Conditions and Treatments

    • Condition | Sperm Count (million/mL) | Treatment
    • Oligospermia | 10-15 | IUI
    • | 5-10 | IVF
    • | < 5 | ICSI

    Common causes of asthenospermia:

    • Kartagener syndrome / Immotile cilia
    • Recurrent sinusitis + Recurrent chest infection d/t Bronchiectasis
    • Infertility
    • Smoking
    • Young's syndrome
    • Mucus thickening → Blockade of nose, bronchi & vas deferens
    • Oligospermia + Asthenospermia + Teratozoospermia
    • Seen in varicocele & smoking

    Klinefelter Syndrome

    • 47XXY
    • Incidence: 1 - 2.5/1000 pregnancies
    • Characteristics:
      • Tall, long limbs
      • Gynecomastia
      • Hyposplastic testicles
      • Increased risk of breast cancer, Non-Hodgkin's lymphoma, Extragonadal germ cell tumor
      • Decreased life span, IQ

    Note:

    • The text includes diagrams that are not reproducible in this format.
    • The approximate size and location of organs are presented in the diagrams.
    • The document contains abbreviations that might not be readily understandable without further context. More information is needed for clarification.

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    Description

    This quiz explores various contraception methods, including oral contraceptives like POP and progesterone implants, as well as long-acting reversible contraceptives such as IUDs. It also covers permanent methods like tubal ligation and vasectomy, and discusses considerations for individuals with epilepsy. Test your knowledge on these important reproductive health topics!

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