[18] Investigations of Infertility Flashcards
1
Q
What investigations are used to assess for male infertility?
A
- Semen analysis
- Analysis of sperm DNA
- Endocrine assessment
- Cytogenic studies
- Testicular/epididymal biopsy
- Tests for retrograde ejaculation
- Immunological tests
2
Q
What is the most useful investigation into male infertility?
A
Semen analysis
3
Q
How are semen samples collected?
A
Masturbation into a sterile container after 3 days abstinence and examined within 2 hours of collection
4
Q
Where is the best place for semen sample collection?
A
In a private room adjacent to the androgeny laboratory to avoid cooling during transportation
5
Q
What is the lower limit of normal semen volume?
A
1.5ml
6
Q
What is the lower limit of normal total sperm number?
A
39x10^6 per ejaculate
7
Q
What is the lower limit of normal sperm concentration?
A
15x10^6 per ml
8
Q
What is the lower limit of normal total sperm motility?
A
40%
9
Q
What is the lower limit of normal progressive sperm motility?
A
32%
10
Q
What is the lower limit of normal sperm vitality (live sperm)?
A
58%
11
Q
What is the lower limit of normal sperm morphology?
A
4%
12
Q
What are the main features looked at in seme analysis?
A
- Volume
- Sperm concentration
- Motility
13
Q
What is the semen volume range for 80% of fertile males?
A
1-4ml
14
Q
What may a low semen volume suggest?
A
Androgen deficiency
15
Q
What may a high semen volume suggest?
A
Abnormal accessory gland function
16
Q
What is absence of sperm in semen called?
A
Azoospermia
17
Q
What does azoospermia indicate?
A
Sterility
18
Q
How may sperm be obtainable in azoospermia?
A
- Percutaneous epididymal aspiration
- Testicular aspiration
- Testicular biopsy
19
Q
Why should findings if sperm concentration not be accepted on a single sample?
A
Can vary from day to day
20
Q
What might abnormally high values of sperm concentration be associated with?
A
Subfertility
21
Q
What would be an abnormally high sperm concentration?
A
> 200 million per ml
22
Q
What % of sperm should show good motility within an hour of collection?
A
60%
23
Q
How does WHO grade sperm motility?
A
Grades 1-4
24
Q
What is grade 1 sperm motility?
A
Rapid and linear progressive motility
25
What is grade 2 sperm motility?
Slow or sluggish linear or non-linear motility
26
What is grade 3 sperm motility?
Non-progressive motility
27
What is grade 4 sperm motility?
Immotile
28
Why may analysis of sperm DNA be performed as an investigation for infertility?
Integrity of sperm DNA is essential for normal fertilisation and transmission of paternal genetic information
29
What may damage to sperm DNA lead to?
Impaired fertility
30
What endocrine results suggest testicular damage?
High serum concentrations of FSH and low AMH
31
What endocrine results suggest male hypopituitarism?
Low or undetectable FSH and LH
32
What endocrine results are found in spermatogenic failure?
High FSH, low AMH and azoospermia
33
What may hyperprolactinaemia cause in males in terms of infertility?
Impotence or oligospermia
34
What should be looked for on cytogenic tests for male infertility?
XXY or XYY karyotypes
35
What genetic condition should oligospermic men be screened for?
Cystic fibrosis
36
Why is it important to screen oligospermic men for CF?
They may be healthy carriers and conceive with assistance to produce a child with CF if their partner is a carrier
37
Why can a testicular/epididymal biopsy be useful in assessing male infertility?
- May demonstrate spermatogenesis even if elevated concentrations of gonadotrophins
- Sperm can be aspirated and cryopreserved for later
38
How can retrograde ejaculation be investigated?
Detecting spermatozoa in the urine
39
When should retrograde ejaculation be considered as a more likely cause of infertility?
Following TURP
40
Why are immunological tests a useful investigation for infertility?
Autoimmunity to sperm can cause infertility
41
What class are the anti-sperm antibodies?
IgG and IgA
42
What is the first step in assessing female infertility?
Examination
43
What are the important aspects of an examination for female infertility?
- Signs of hirsutism
- Abdominal examination
- Gynaecological examination
- Bimanual examination
44
What are some associated features of hirsutism?
- Facial hair
- Acne
- Male pattern alopecia
- Pubic hairline extending to umbilicus
45
What findings on bimanual examination might explain infertility?
- Adnexal mass from ovary or tubes
- Tenderness suggesting PID or endometriosis
- Presence of uterine fibroids
46
What is the first step in assessing ovulation?
Detecting if it is taking place
47
If a regular menstrual cycle is present what measures can be used to investigate whether ovulation is taking place?
- Changes in basal body temperature or cervical mucus
- Measurement of hormonal levels
- Endometrial biopsy
- Ultrasound
48
Are measurements of body temperature and cervical mucus recommended as indicators of ovulation?
No
49
Why is measuring body temperature not recommended as a way of identifying ovulation?
Difficult and increases the stress with a daily reminder of failure to conceive
50
Why is monitoring cervical mucus not recommended as a way to identify ovulation?
Many women find the assessment difficult
51
What changes in hormones suggests ovulation is taking place?
LH surge in blood or urine
52
When does the peak of the LH surge occur?
24 hours before ovulation
53
How can women assess their ovulation using hormones?
Commercially available LH detection kits
54
How can formation of the corpus luteum be demonstrated with hormone measurements?
Serum progesterone in the luteal phase
55
What progesterone measurement in the mid-luteal phase is suggestive of ovulation?
>25mmol/L
56
How can ultrasound help assess ovulation?
- Transvaginal can be used to track follicle growth
| - May help diagnosis of PCOS or ovarian endometrioma
57
How should evidence of anovulation be further investigated?
- Serum prolactin and TFT
- Serum FSH, LH and oestradiol on days 2 and 3 of natural or induced menstruation
- Measurement of AMH
58
If prolactinaemia is present in anovulation what additional test should be performed?
MRI or CT of sella turcica
59
How can ovarian reserve be assessed?
Using measurements of AMH in serum or antral follicle count with transvaginal ultrasound
60
What does a low age-related AMH or AFC predict?
Poor oocyte yield at IVF and lower chance of pregnancy
61
What does a higher AMH or AFC predict in infertility?
Better ovarian response to gonadotrophin stimulation
62
What is the limitation of assessing ovarian reserve?
Can predict oocyte quantity but not quality
63
What tests can be used to assess tubal patency?
- Hysterosalpingography
| - Laparoscopy and dye insufflation
64
When is assessment of tubal patency necessary?
Before beginning ovulation therapy or intrauterine insemination
65
When is assessment of tubal patency not necessary?
If the couple are going straight to IVF
66
How is hysterosalpingography performed?
Radio-opaque dye injected into the uterine cavity and fallopian tubes to outline the uterus and tubes
67
How can hysterosalpingography show tubal patency?
Will highlight any obstructions and their site
68
When should hysterosaplingography be performed?
Within the first 10 days of the cycle
69
Why should hysterosalpingography be performed in the first 10 days of the cycle?
To avoid inadvertent irradiation of a newly fertilised embryo
70
What should women be screened for before hysterosalpingography?
Chlamydia trachomatis
71
Why should women be screened for chlamydia before hysterosalpingography?
Reduce the risk of reactivation of infection leading to pelvic abscess formation
72
What does laparoscopy help to identify when investigating infertility?
Directly visualises the pelvic organs to assess for endometriosis or adhesions
73
What is dye insufflation?
Methylene blue dye is injected through the cervix to test tubal patency
74
What is the 'see and treat' policy of diagnostic laparoscopy for infertility?
Allowing for rapid surgical treatment of minor degrees of endometriosis or adhesions
75
When is intervention for a pathology diagnosed on laparoscopy best left to another surgery?
When intervention may damage other pelvic structures to get full informed consent
76
What are the risks of laparoscopy?
- GA
| - Damage to other pelvic structures
77
Why is laparoscopy preferred as a later investigation for infertility?
Due to its risks less invasive procedures are preferred first
78
When may a laparoscopy be the first line investigation for infertility?
Specific indications e.g. history of PID or appendicitis with peritonitis
