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4: Y4 - Gynaecology [8] > [18] Investigations of Infertility > Flashcards

[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
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2
Q

What is the most useful investigation into male infertility?

A

Semen analysis

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3
Q

How are semen samples collected?

A

Masturbation into a sterile container after 3 days abstinence and examined within 2 hours of collection

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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

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5
Q

What is the lower limit of normal semen volume?

A

1.5ml

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6
Q

What is the lower limit of normal total sperm number?

A

39x10^6 per ejaculate

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7
Q

What is the lower limit of normal sperm concentration?

A

15x10^6 per ml

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8
Q

What is the lower limit of normal total sperm motility?

A

40%

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9
Q

What is the lower limit of normal progressive sperm motility?

A

32%

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10
Q

What is the lower limit of normal sperm vitality (live sperm)?

A

58%

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11
Q

What is the lower limit of normal sperm morphology?

A

4%

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12
Q

What are the main features looked at in seme analysis?

A
  • Volume
  • Sperm concentration
  • Motility
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13
Q

What is the semen volume range for 80% of fertile males?

A

1-4ml

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14
Q

What may a low semen volume suggest?

A

Androgen deficiency

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15
Q

What may a high semen volume suggest?

A

Abnormal accessory gland function

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16
Q

What is absence of sperm in semen called?

A

Azoospermia

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17
Q

What does azoospermia indicate?

A

Sterility

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18
Q

How may sperm be obtainable in azoospermia?

A
  • Percutaneous epididymal aspiration
  • Testicular aspiration
  • Testicular biopsy
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19
Q

Why should findings if sperm concentration not be accepted on a single sample?

A

Can vary from day to day

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20
Q

What might abnormally high values of sperm concentration be associated with?

A

Subfertility

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21
Q

What would be an abnormally high sperm concentration?

A

> 200 million per ml

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22
Q

What % of sperm should show good motility within an hour of collection?

A

60%

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23
Q

How does WHO grade sperm motility?

A

Grades 1-4

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24
Q

What is grade 1 sperm motility?

A

Rapid and linear progressive motility

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25
Q

What is grade 2 sperm motility?

A

Slow or sluggish linear or non-linear motility

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26
Q

What is grade 3 sperm motility?

A

Non-progressive motility

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27
Q

What is grade 4 sperm motility?

A

Immotile

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28
Q

Why may analysis of sperm DNA be performed as an investigation for infertility?

A

Integrity of sperm DNA is essential for normal fertilisation and transmission of paternal genetic information

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29
Q

What may damage to sperm DNA lead to?

A

Impaired fertility

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30
Q

What endocrine results suggest testicular damage?

A

High serum concentrations of FSH and low AMH

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31
Q

What endocrine results suggest male hypopituitarism?

A

Low or undetectable FSH and LH

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32
Q

What endocrine results are found in spermatogenic failure?

A

High FSH, low AMH and azoospermia

33
Q

What may hyperprolactinaemia cause in males in terms of infertility?

A

Impotence or oligospermia

34
Q

What should be looked for on cytogenic tests for male infertility?

A

XXY or XYY karyotypes

35
Q

What genetic condition should oligospermic men be screened for?

A

Cystic fibrosis

36
Q

Why is it important to screen oligospermic men for CF?

A

They may be healthy carriers and conceive with assistance to produce a child with CF if their partner is a carrier

37
Q

Why can a testicular/epididymal biopsy be useful in assessing male infertility?

A
  • May demonstrate spermatogenesis even if elevated concentrations of gonadotrophins
  • Sperm can be aspirated and cryopreserved for later
38
Q

How can retrograde ejaculation be investigated?

A

Detecting spermatozoa in the urine

39
Q

When should retrograde ejaculation be considered as a more likely cause of infertility?

A

Following TURP

40
Q

Why are immunological tests a useful investigation for infertility?

A

Autoimmunity to sperm can cause infertility

41
Q

What class are the anti-sperm antibodies?

A

IgG and IgA

42
Q

What is the first step in assessing female infertility?

A

Examination

43
Q

What are the important aspects of an examination for female infertility?

A
  • Signs of hirsutism
  • Abdominal examination
  • Gynaecological examination
  • Bimanual examination
44
Q

What are some associated features of hirsutism?

A
  • Facial hair
  • Acne
  • Male pattern alopecia
  • Pubic hairline extending to umbilicus
45
Q

What findings on bimanual examination might explain infertility?

A
  • Adnexal mass from ovary or tubes
  • Tenderness suggesting PID or endometriosis
  • Presence of uterine fibroids
46
Q

What is the first step in assessing ovulation?

A

Detecting if it is taking place

47
Q

If a regular menstrual cycle is present what measures can be used to investigate whether ovulation is taking place?

A
  • Changes in basal body temperature or cervical mucus
  • Measurement of hormonal levels
  • Endometrial biopsy
  • Ultrasound
48
Q

Are measurements of body temperature and cervical mucus recommended as indicators of ovulation?

A

No

49
Q

Why is measuring body temperature not recommended as a way of identifying ovulation?

A

Difficult and increases the stress with a daily reminder of failure to conceive

50
Q

Why is monitoring cervical mucus not recommended as a way to identify ovulation?

A

Many women find the assessment difficult

51
Q

What changes in hormones suggests ovulation is taking place?

A

LH surge in blood or urine

52
Q

When does the peak of the LH surge occur?

A

24 hours before ovulation

53
Q

How can women assess their ovulation using hormones?

A

Commercially available LH detection kits

54
Q

How can formation of the corpus luteum be demonstrated with hormone measurements?

A

Serum progesterone in the luteal phase

55
Q

What progesterone measurement in the mid-luteal phase is suggestive of ovulation?

A

> 25mmol/L

56
Q

How can ultrasound help assess ovulation?

A
  • Transvaginal can be used to track follicle growth

- May help diagnosis of PCOS or ovarian endometrioma

57
Q

How should evidence of anovulation be further investigated?

A
  • Serum prolactin and TFT
  • Serum FSH, LH and oestradiol on days 2 and 3 of natural or induced menstruation
  • Measurement of AMH
58
Q

If prolactinaemia is present in anovulation what additional test should be performed?

A

MRI or CT of sella turcica

59
Q

How can ovarian reserve be assessed?

A

Using measurements of AMH in serum or antral follicle count with transvaginal ultrasound

60
Q

What does a low age-related AMH or AFC predict?

A

Poor oocyte yield at IVF and lower chance of pregnancy

61
Q

What does a higher AMH or AFC predict in infertility?

A

Better ovarian response to gonadotrophin stimulation

62
Q

What is the limitation of assessing ovarian reserve?

A

Can predict oocyte quantity but not quality

63
Q

What tests can be used to assess tubal patency?

A
  • Hysterosalpingography

- Laparoscopy and dye insufflation

64
Q

When is assessment of tubal patency necessary?

A

Before beginning ovulation therapy or intrauterine insemination

65
Q

When is assessment of tubal patency not necessary?

A

If the couple are going straight to IVF

66
Q

How is hysterosalpingography performed?

A

Radio-opaque dye injected into the uterine cavity and fallopian tubes to outline the uterus and tubes

67
Q

How can hysterosalpingography show tubal patency?

A

Will highlight any obstructions and their site

68
Q

When should hysterosaplingography be performed?

A

Within the first 10 days of the cycle

69
Q

Why should hysterosalpingography be performed in the first 10 days of the cycle?

A

To avoid inadvertent irradiation of a newly fertilised embryo

70
Q

What should women be screened for before hysterosalpingography?

A

Chlamydia trachomatis

71
Q

Why should women be screened for chlamydia before hysterosalpingography?

A

Reduce the risk of reactivation of infection leading to pelvic abscess formation

72
Q

What does laparoscopy help to identify when investigating infertility?

A

Directly visualises the pelvic organs to assess for endometriosis or adhesions

73
Q

What is dye insufflation?

A

Methylene blue dye is injected through the cervix to test tubal patency

74
Q

What is the ‘see and treat’ policy of diagnostic laparoscopy for infertility?

A

Allowing for rapid surgical treatment of minor degrees of endometriosis or adhesions

75
Q

When is intervention for a pathology diagnosed on laparoscopy best left to another surgery?

A

When intervention may damage other pelvic structures to get full informed consent

76
Q

What are the risks of laparoscopy?

A
  • GA

- Damage to other pelvic structures

77
Q

Why is laparoscopy preferred as a later investigation for infertility?

A

Due to its risks less invasive procedures are preferred first

78
Q

When may a laparoscopy be the first line investigation for infertility?

A

Specific indications e.g. history of PID or appendicitis with peritonitis

4: Y4 - Gynaecology [8] (52 decks)

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