409.3 🩺 內科專科考前版

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409.3.0.1 📌 一頁重點

• 22E updates:
  • Letrozole > clomiphene for PCOS ovulation (PPCOS II)
  • AMH preferred over Day 3 FSH for ovarian reserve
  • Y microdeletion + CFTR + Klinefelter standard for severe male factor
  • TESE + ICSI for Klinefelter: ~ 50% sperm retrieval
  • Pre-implantation genetic testing (PGT-A/M): chromosomal + monogenic screening
  • Egg freezing (oocyte cryopreservation): standard option for fertility preservation
  • Uterus transplant for MRKH: emerging, successful births
• Taiwan: 健保 IUI 條件; 健保 IVF 限制 (selected); 健保 ICSI 條件; 健保 TESE 條件; 健保 letrozole/clomiphene; 健保 contraception (COC, IUD, condoms 部分); 健保 sterilization

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409.3.0.2 🌟 Pearls (12)

1. AMH < 1 ng/mL = diminished ovarian reserve; predictor of IVF response
2. AMH > 3.5 ng/mL = high responder; OHSS risk
3. Day 3 FSH less reliable; AMH preferred
4. Letrozole 5 mg for PCOS ovulation (PPCOS II): higher live birth than clomiphene
5. Aromatase inhibitor doesn’t have anti-estrogen on endometrium (vs clomiphene which thins endometrium)
6. Klinefelter TESE: best 14-30 yr; declines with age; spermatogonia preserved 不一定 spermatozoa
7. CBAVD + CFTR mutation: 80% of obstructive azoospermia in non-CF context; check partner CFTR carrier status
8. Y chromosome microdeletion (AZF): AZFa, AZFb, AZFc; AZFc has best chance of TESE
9. OHSS prevention: GnRH agonist trigger (no hCG), letrozole + GnRH antagonist, embryo freezing all
10. Drospirenone + estrogen (COC): more DVT risk than other progestin combos
11. Anti-mitotic exposure pre-conception (chemo): consider sperm/egg cryo + GnRH agonist for ovarian shielding
12. Pre-implantation genetic testing:
    • PGT-A: aneuploidy (chromosomal)
    • PGT-M: monogenic disorders
    • PGT-SR: structural rearrangement

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409.3.0.3 📍 Taiwan + 健保

409.3.0.3.1 Drugs

• 健保 letrozole, clomiphene, metformin
• 健保 gonadotropin (hMG, recombinant FSH) 條件
• 健保 GnRH agonist + antagonist (條件 for IVF)
• 健保 ovulation tracking
• 健保 hCG trigger

409.3.0.3.2 Contraception

• 健保 COC (multiple types) — 部分自費
• 健保 progestin-only pill
• 健保 levonorgestrel IUD (Mirena)
• 健保 copper IUD
• 健保 emergency contraception (levonorgestrel 1.5 mg)
• 健保 sterilization (tubal + vasectomy)
• Implant (Nexplanon) 自費 多
• Patch / ring 自費

409.3.0.3.3 ART

• 健保 IUI 條件
• 健保 IVF 限制 (selected; usually self-pay)
• 健保 ICSI 條件
• 健保 TESE/PESA 條件
• 健保 oocyte freezing 限制 (cancer, endometriosis 條件; cosmetic 自費)
• PGT 自費
• Donor egg/sperm 限制 + 自費
• Gestational carrier Taiwan 法律限制

409.3.0.3.4 學會 + 指引

• TES + TAOG (婦產) + 國健署 unwanted pregnancy program
• ASRM (American Society for Reproductive Medicine)
• ESHRE Guidelines
• WHO Family Planning Guidelines

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409.3.0.4 🎓 內專必懂 (12)

1. Infertility definition + epidemiology
2. Female workup algorithm + AMH preference
3. Male workup + WHO 2010 semen criteria
4. Klinefelter / Y microdeletion / CFTR for severe male
5. Ovulation induction (letrozole > clomiphene PCOS)
6. IUI vs IVF vs ICSI
7. OHSS prevention + management
8. Pre-implantation genetic testing (PGT-A/M/SR)
9. Fertility preservation pre-chemo
10. Contraception spectrum + efficacy + CI
11. Emergency contraception 3 options + timing
12. 22E new: AMH adoption, uterus transplant, fertility preservation expansion

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409.3.0.5 ⚙️ Female Infertility Algorithm (內專)

Step 1 — History + Exam:
- Cycle pattern (regular vs oligomenorrhea)
- BMI
- Sexual frequency + timing
- Past STI / PID
- Endometriosis features
- Family Hx

Step 2 — Lab:
- TSH + prolactin
- AMH (preferred ovarian reserve marker)
- Day 3 FSH (alternate)
- Cycle Day 21 progesterone (ovulation confirmation)
- 17-OH-prog if hirsutism

Step 3 — Imaging:
- TVS (structural + AFC)
- HSG (tubal patency + uterine cavity)
- Saline infusion sonography for cavity detail
- Hysteroscopy if cavity issues
- MRI for endometriosis / fibroid mapping

Step 4 — Determine Treatment Path:
- Ovulatory dysfunction:
  - PCOS → letrozole (1st), clomiphene, metformin adjunct, gonadotropin
  - Hypothalamic → restore weight + lifestyle; pulsatile GnRH
  - POI → donor egg
  - Hyperprolactinemia → cabergoline
- Tubal:
  - Surgery (lysis adhesions, salpingostomy)
  - IVF (preferred for severe)
- Endometriosis:
  - Surgery for severe
  - IVF for moderate-severe + age ≥ 35
- Uterine:
  - Hysteroscopy (polyp, fibroid, adhesions)
- Unexplained:
  - Ovulation induction + IUI
  - IVF after several IUI failures
- Age 38+ with diminished reserve:
  - Direct IVF or donor egg

Step 5 — ART:
- Controlled ovarian stim
- Embryo transfer (fresh vs frozen)
- PGT-A in selected
- Single embryo transfer (reduce multiple gestation)
- Cryopreserve remaining

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409.3.0.6 ⚙️ OHSS Management (內專)

Severity:
- Mild: abdominal distension, pelvic discomfort
- Moderate: ascites, vomiting, weight gain > 2 kg
- Severe: severe ascites, hemoconcentration, electrolyte disturbance, oliguria
- Critical: thromboembolism, ARDS, multi-organ failure

Management:
- Mild: outpatient symptomatic
- Moderate: hospital, fluid + electrolytes, paracentesis if symptomatic
- Severe: ICU, IV fluids, paracentesis, anticoagulation prophylaxis
- Critical: aggressive multi-organ support

Prevention:
- GnRH agonist trigger (no hCG) in high responder
- Coasting (delay hCG)
- Cabergoline 0.5 mg/d × 8 d (reduces VEGF effect)
- Letrozole + GnRH antagonist protocol
- Embryo freezing all (avoid pregnancy hCG enhancement)

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409.3.0.7 ⚙️ Fertility Preservation Pre-Chemo

Female:
- Oocyte cryopreservation (most established)
  - Controlled stim + retrieval
  - Vitrification
  - 2-4 wk delay if possible
- Embryo cryopreservation (if partner)
- Ovarian tissue cryopreservation (research / for prepubertal)
- GnRH agonist co-treatment with chemo (controversial; some benefit)
- Ovarian shielding (RT)

Male:
- Sperm cryopreservation (gold standard)
  - Pre-puberty: testicular tissue (research)
- TESE then cryopreservation if azoospermic

Considerations:
- Cancer urgency vs preservation time
- Multiple cycles for higher yield
- Discuss + plan early
- Insurance / cost (often self-pay)
- Ethics + family planning
- Onco-fertility multidisciplinary

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