Assessment of Infertility

Question 1

epidemiology of infertility (3)

Answer 1

15% couples

half of these couples will conceive either spontaneously or with relatively simple advice or treatment.

8% of the population remain subfertile and require more complex treatment such as assisted conception techniques.

Question 2

chance of spontaneous pregnancy (3)

Answer 2

6 months: 75%

12 months: 90%

2 years: 95%

Question 3

definition of infertility

Answer 3

failure to achieve a clinical pregnancy after 12 months of more of regular unprotected sexual intercourse (in absence of known reason) in a couple who have never had a child

Question 4

infertility

Answer 4

causes considerable psychological distress (health:‘a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity’).

Question 5

primary

Answer 5

(couple never conceived)

Question 6

secondary

Answer 6

(couple previously conceived, although pregnancy may not have been successful e.g. miscarriage or ectopic pregnancy)

Question 7

factors affecting infertility- increasing chance of conception (8)

Answer 7

-Woman aged under 30 years
-Previous pregnancy
-Less than three years trying to conceive
-Intercourse occurring around ovulation
-Woman’s (BMI) 18.5 – 30m/kg2
-Both partners non-smokers
-Caffeine intake less than two cups of coffee daily
-No use of recreational drugs

Question 8

causes of secondary infertility (5)

Answer 8

-tubal disease
-fibroids
-endometriosis/adenomyosis
-weight related
-age related

Question 9

Anovulatory Infertility- physiological (4)

Answer 9

-before puberty
-pregnancy
-lactation
-menopause

Question 10

Anovulatory Infertility- gynae (hypothalmic) (2)

Answer 10

anorexia/bulimia

excessive exercise

Question 11

Anovulatory Infertility- gynae (pituitary) (3)

Answer 11

hyperprolactinaemia

tumours

Sheehan syndrome

Question 12

Anovulatory Infertility- gynae (ovarian) (2)

Answer 12

PCOS

premature ovarian failure

Question 13

Anovulatory Infertility- other conditions (10)

Answer 13

Systematic disorder: e.g. chronic renal failure.

Endocrine disorder: e.g. testosterone secreting tumours, congenital adrenal hyperplasia, thyroid

Drugs: e.g. depo-provera, explanon, OCP

Question 14

anorexia nervosa

Answer 14

1% population- females 85-95%

aetiology=social-cultural, family pathology, genetic

outcome= at 6 years: 1/3 cured, 1/3 ongoing, 1/3 worse (6-10% mortality)

Question 15

anorexia nervosa- symptoms, signs + endo features (17)

Answer 15

weight loss, increase exercise, withdrawl friends, amenorrrhoea

low BMI (below 18.5), loss of hair, increased lanugo, low pulse and BP, anaemia, dehydration, reduced bone density, muscle loss and weakness

FSH, LH and oestradiol

Question 16

polycystic ovary syndrome

Answer 16

commonest endocrine disorder in women (20-33%)

aetiology: inherited condition, weight gain exacerbates condition

Question 17

polycystic ovary syndrome- symps + endo features (7)

Answer 17

S- obesity, hirsutism or acne, menstrual cycle abnormalities and infertility

E- high free androgens, high LH, impaired glucose tolerance

Question 18

polycystic ovary syndrome- diagnosis (4)

Answer 18

score 2 out of three:
-chronic anovulation
-polycystic ovaries
-hyperandrogenism (clinical or biochemical)

Question 19

premature ovarian failure (7)

Answer 19

1% before age 40 years

aetiology:
-idiopathic
-genetic (Turner’s syndrome- missing x chromosome)
(fragile X)
-chemotherapy, radiotherapy, oophorectomy

Question 20

premature ovarian failure - symps + endo features (8)

Answer 20

S- hot flushes, night sweats, atrophic vaginitis, amenorrhoea, infertility

E- high FSH, high LH, low oestradiol

Question 21

tubal disease- causes = infective (11)

Answer 21

-Pelvic inflammatory disease
(chlamydia, gonorrhoea, other: anaerobes, syphilis, TB)

-transperitoneal spread:
appendicitis, intra-abdominal abscess

-following procedure: IUCD insertion, hysteroscopy, HSG

Question 22

tubal disease- causes = non infective (6)

Answer 22

-endometriosis
-surgical (sterilisation, ectopic pregnancies)
-fibroids
-polyps
-congenital
-salpingitis isthmica nodosa

Question 23

hydrosalpinx due to pelvic inflam disease- features (6)

Answer 23

-abdominal/pelvic pain febrile
-vaginal discharge dyspareunia
-cervical excitation menorrhagia
-dysmenorrhoea
-infertility
-ectopic pregnancy

Question 24

endometriosis (6)

Answer 24

presence of endometrial glands outside uterine cavity

approx. 20% (10% menstruating women, 30% women with infertility)

aetiology: retrograde menstruation is most likely cause, altered immune function, abnormal cellular adhesion molecules, genetic

Question 25

endometriosis- features (9)

Answer 25

-dysmenorrhoea (classically before menstruation)
-dysparenuia
-menorrhagia
-painful defaecation
-chronic pelvic pain
-uterus may be fixed and retroverted
-scan may show characteristic ‘chocolate’ cysts on ovary
-infertility
-asymptomatic

Question 26

male infertility (9)

Answer 26

30-50% of male infertility is idiopathic

male factors- hypogonadism, sexual fact, urogenitial inf , undescended testes

enviro/lifestyle factors- occupational, smoking, alcohol, obesity

Question 27

causes male infertility- pre testicular (8)

Answer 27

endocrine:
-hypogonadotropic hypogonadism
-hypothyroidism
-hyperprolactinaemia
-diabetes

coital:
-erectile dysfunction
-ejaculatory failure

Question 28

causes male infertility- testicular (12)

Answer 28

genetic:
-klinefelter syndrome
-Y chromosome deletion
-immotile cilia syndrome

congenital:
-infective
-cyptorchidism
-antispermatogenic agents= heat, drug, irradiation

vascular:
-torsion
-varicocele

immunological

Question 29

causes male infertility- post testicular (12)

Answer 29

OBSTRUCTIVE

epdidymal:
-congenitive
-infective

vasal:
-CF
-vasectomy
-ejaculatory duct obstruction
-accessory gland infection
-immunological
-idiopathic
-post vasectomy

Question 30

non- obstructive- causes (5)

Answer 30

47 XXY, chemotherapy, radiotherapy, undescended testes, idiopathic

Question 31

non- obstructive- features (8)

Answer 31

features:
-low testicular volume
-reduced secondary sexual characteristics
-vas deferens present

endocrine features:
High LH, FSH and low testosterone

Question 32

obstructive- causes (3)

Answer 32

congenital absence (cystic fibrosis), infection, vasectomy

Question 33

obstructive- features (8)

Answer 33

features:
-normal testicular volume
-normal secondary sexual characteristics
-vas deferens may be absent

endocrine features:
Normal LH, FSH and testosterone

Question 34

investigation of infertility

Answer 34

History: infertility history, gynaecology, andrology, sexual H, social H, PMH, PSH, POH

Question 35

Examination of female (7)

Answer 35

BMI

General examination:
assessing body hair distribution
galactorrhoea

Pelvic examination:
assessing for uterine + ovarian abnorm/tender/mobility

Question 36

Examination of male (7)

Answer 36

BMI

General examination

Genital examination:
-assessing size/position testes
-penile abnormalities
-presence vas deferens
-presence varicoceles

Question 37

investigation of female (6)

Answer 37

-endocervical swab for chlamydia
-cervical smear if due
-blood for rubella immunity
-midluteal progesterone level
(day 21 of 28 day cycle or 7 days prior to expected period in prolonged cycles), progesterone > 30nmol/l suggestive ovulation

Question 38

Female- test of tubal patency (4)

Answer 38

if nil known risk factors tubal/ pelvic pathology

HSG= normal

bilateral hydrosalpinx

Hycosy= normal

Question 39

Female- test of tubal patency- laparoscopy

Answer 39

laparoscopy contradicted in=
i.e. obesity, previous pelvic surgery, Crohn’s disease

Question 40

Female- pelvic ultrasound

Question 41

Female- endocrine profile and chromosomes

Question 42

investigation of male

Question 43

commonly used normal semen parameters

Question 44

Male- other assessments

Question 45

Male- testicular ultrasound