Chapter 18: Infertility Flashcards
INFERTILITY. You are a trainee intern in a general practice. You are seeing Liz, a 26 year old Pākehā woman who has recently stopped the combined oral contraceptive pill as she would like to conceive. She presents wishing to know whether she is ovulating. From the following options, which symptom would best CONFIRM for Liz that she is likely ovulating?
- Breast tenderness a week before her period
- Periods painful on first or second day
- Regular and predictable periods each month
- Clots with her periods?
- Thicker mucus at midcycle
- Heavy menstrual loss
- Regular and predictable periods each month
A regular predictable cycle means that a woman such as Liz is likely ovulating. Breast tenderness, clotting, menstrual loss, pain and mucus may be features of an ovulatory cycle, but are unreliable in regards to confirmation of ovulation.
INFERTILITY. You are a trainee intern in general practice with Rosie, a 28 year old G0P0 NZ European woman. She has a 2 year history of primary infertility, and her periods have become increasingly painful over the last 3 years. Her periods are regular and not heavy. Her 31 year old husband has a 6 year old child by a previous relationship. Neither have had treatment for a sexually transmitted infection. Examination reveals a fixed and retroverted uterus. There is tenderness in the posterior fornix and nodules are palpable on the utero-sacral ligaments. From the options provided, select the MOST LIKELY cause of their infertility.
- Endometriosis
- Adenomyosis
- Fibroids
- Pelvic Inflammatory Disease
- Low sperm count / male factor infertility
- PCOS
- Endometriosis
The symptoms and signs are suggestive of endometriosis, which accounts for around 10% of infertility, and is contributory of a further 30%. The degree of endometriosis in this woman is likely to be moderate to severe. Pelvic inflammatory disease in most cases results from an ascending infection from the lower genital tract. Adenomyosis is difficult to diagnose clinically and its association with infertility is controversial. Nodules palpated on the uterosacral ligaments are a classical association with endometriosis. PCOS is most commonly associated with irregular periods and normal vaginal findings.
You are a trainee intern in general practice with Manaia and Nikau, a Māori couple both of whom are aged 28 years. They have been together for two years and stopped condom contraception two months ago. He had bilateral orchidopexies when aged 6 yrs. His testis volumes are both 16 mls (N=15 – 25mls). Because of the history of testis surgery, your colleague had arranged a semen analysis. They present to discuss the results. Nikau’s semen analysis shows: Volume 5 ml (N= 2-6 ml) Concentration 22 million per ml(N > 15 million per ml) Total motility 70% (N > 40%) Which of the following options is the MOST APPROPRIATE management?
- Refer to the local hospital for consideration of laparoscopy and tubal dye studies
- Repeat the semen analysis at the laboratory in a month
- Reassurance and offer review in 6 to 9 months if they have not conceived
- Arrange a hysterosalpingogram
- Refer to a tertiary fertility provider for consideration of IVF with ICSI
- Reassurance and offer review in 6 to 9 months if they have not conceived
Nikau has a normal examination and semenanalysis. Repeating the semen test at the local lab is also not necessary – that is recommended only if the result is abnormal. No further investigation or fertility treatment is warranted at this stage as the couple have been trying to conceive for only two months.
You are a trainee intern in a gynaecology clinic seeing Zara, a 29-year-old Pākehā woman and her 31-year-old male partner. They have been referred because of a 1 year history of primary infertility. The couple have sexual intercourse 2-3 times per week. Zara has regular cycles every 27-30 days, without any abnormal pain or bleeding. Examination is normal. You arrange various blood investigations. Of the following options, what is the MOST IMPORTANT blood test to confirm that Zara has a normal ovulatory cycle?
A. Day 21 or day 22 serum progesterone
B. Day 2-3 serum FSH
C. Day 14 serum LH
D. Day 8 serum progesterone
E. Day 21 or day 22 oestradiol
A. Day 21 or day 22 serum progesterone
You are a trainee intern in general practice. You are seeing Amber, a 28 year old nulligravid Pākehā woman who wishes to be referred to fertility services as she and her wife Moana wish to conceive a baby using donor sperm. Prior to the referral, you arrange routine bloods, vaginal swabs and a cervical smear. Which of the following test results would require TREATMENT prior to Amber embarking on fertility treatment?
A. Blood Group A Negative
B. Hep B (s) Antigen: Negative
C. Rubella IgG Antibody: 5 IU/ l (Normal >11)
D. Red Cell antibody negative
E. Chlamydia swab: Negative
F. Syphilis EIA screen: Non-reactive
G. Cytology - Cervical Smear; Satisfactory for evaluation; Negative for intraepithelial lesion or malignancy
C. Rubella IgG Antibody: 5 IU/ l (Normal >11)
Initial investigations of the female include a rubella screen, with a normal result being 11 or greater IU/L. Rubella infection during pregnancy can be devastating to the fetus. Fetal complications of maternal infection include cardiac malformations, microcephaly, cataracts, cognitive impairment and hearing abnormalities. The risk of congenital rubella syndrome is highest when maternal infection occurs at less than 11 weeks gestation. Pre-pregnancy vaccination essentially prevents maternal risk. Conception should be avoided for one month as the vaccine is a live attenuated vaccine.
You are a trainee intern in a general practice. You see a couple (both Samoan) who have a 12 month history of infertility. Siale, the woman, who is aged 30 years, has had two children from a previous relationship aged 4 and 7 years. Since stopping the oral contraceptive pill 18 months ago she has had regular 27-30 day menstrual cycles with no abnormal bleeding or pain. The couple have been having sexual intercourse 3-4 times per week. LH ovulation detection kits are positive on Day 13-14, and they are ensuring they are having regular coitus around this time. Her partner is aged 30 and has not had any pregnancies in previous relationships. Neither have ever had a sexually transmitted infection. Genital examination of both partners is normal. From the options provided, select which initial investigation is MOST LIKELY to be ABNORMAL given the above history?
A. Anti-Mullerian Hormone
B. Semen analysis
C. Pelvic ultrasound
D. Day 2-4 FSH and/or E2
E. Rubella serology
F. Day 21 progesterone
G. Hysterosalpingogram
B. Semen analysis
Siale does not have an ovulatory problem, and a tubal problem is unlikely as her previous fertility has been very normal and ovarian reserve (as judged by Day 2-3 FSH and E2, and/or AMH) at her age is unlikely to be compromised, especially given her previous fertility history. As she has never had an STI, tubal disease is unlikely. At least 35% of infertility is male factor. In this case, a semenanalysis is the most likely investigation to be abnormal. Determination of rubella status will not be useful at this time to help determine the cause of the couple’s delay in conceiving.
You are seeing Sarah, a 29-year-old Māori wahine and her 31-year-old male partner who have been referred because of a 1 year history of primary infertility. The couple have regular sexual intercourse 2-3 times per week. Sarah has regular and pain-free menstrual cycles. Examination of both is normal. A semen analysis is also normal. Mid-luteal progesterones have confirmed ovulatory cycles. Day 2-3 FSH and AMH levels are indicative of adequate ovarian reserve. Pelvic ultrasound was normal. Neither partner has any history of sexually transmitted infections. From the following options, what is the BEST NEXT INVESTIGATION recommended?
A. Hysterosalpingogram (HSG) or Hysterosalpingo Contrast Sonography (HyCoSy)
B. Hysteroscopy, D & C
C. Repeat semen analysis
D. Saline sonar hysterogram
E. Hysteroscopy, laparoscopy and tubal insufflation
A. Hysterosalpingogram (HSG) or Hysterosalpingo Contrast Sonography (HyCoSy)
In the presence of a normal transvaginal ultrasound, and the absence of any other obvious cause for delay in achieving pregnancy, tubal patency testing is indicated. As the initial semen analysis is normal, a further test is not necessary. Given there is no reason to suspect pelvic pathology, radiology to assess fallopian tubes is indicated. This may be performed with a hysterosalpingogram or a Hysterosalpingo Contrast Sonography (HyCoSy). If history, examination or ultrasound gives cause to suspect pelvic pathology, then tubal patency testing is generally performed with laparoscopy with tubal dye insufflations. This is performed under general anaesthetic, and will also give the surgeon the opportunity to search for other possible causes of subfertility such as endometriosis. A saline sonar hysterogram is sometimes performed if intrauterine pathology is suspected such as fibroids, polyps or adhesions.
You are a trainee intern in a general practice with Lopini, a 29-year-old G0P0 Tongan woman and her 31-year-old male partner who present with primary infertility for 1 year. The couple have sexual intercourse 2-3 times per week. Lopini has regular periods every 28-29 days. After a full reproductive, sexual, medical and surgical history, examination of both partners is also normal/unremarkable. Which of the following is the next MOST IMPORTANT investigation of their infertility?
A. Semen analysis
B. Karyotyping of both partners
C. Transvaginal pelvic ultrasound
D. Blood tests of ovarian reserve
E. Blood tests to confirm ovulation
F. Blood tests of her thyroid function and prolactin levels
A. Semen analysis
You are trainee intern in general practice. You are about to ring Hone, a 30 year old Māori male whom you saw last week. Hone and his female partner had a primary fertility workup the previous week. History and examination was unremarkable and his partner’s initial tests have been normal. His semen analysis result is: Volume 4ml (N = 2-6ml) Concentration 11 million/ml (N >15) Motility 38% (N >40%) Morphology 8% (N >4%) From the following options, which is the BEST ADVICE for the next step in management?
A. Testicular ultrasound scan
B. Serum testosterone
C. Karyotype
D. Serum FSH
E. Reassure all tests are normal, and review in four months if not pregnant
F. Arrange a repeat sample with 3 days abstinence
F. Arrange a repeat sample with 3 days abstinence
If the result of a man’s first semen analysis is abnormal, a repeat confirmatory test should be offered, particularly when it is only mildly abnormal. Investigation into the cause of mild oligospermia is not indicated as this stage.
You are a trainee intern in general practice with Anna, a 26 year old G0P0 NZ European woman and her 30 year old husband. They have been wanting to conceive for the last 2 months. He has not been able to maintain an erection to achieve penetrative intercourse. He is able to ejaculate with masturbation. History and examination of both are unremarkable. Which of the following options is NOT appropriate?
A. Discuss the use of a medication such as sildenafil (Viagra)
B. Show empathy with the couple, as this may be a difficult topic for them to discuss
C. Agree that feelings such as guilt and self-blame are common feelings in couples who are having similar problems
D. Reassure them that the problem is common
E. Offer referral to a sexual counsellor/ therapist
F. Advise them that they do not meet the definition for infertility until they have been trying for a pregnancy for 12 months
F. Advise them that they do not meet the definition for infertility until they have been trying for a pregnancy for 12 months
You are a trainee intern in general practice with Edith, a 26 year old G0P0 NZ European woman who has just stopped the pill and wishes to become pregnant. Edith is seeking information about the best time to conceive. Prior to going on the pill a year ago, her periods were regular and normal every 28 days. History and examination of her is normal. Her husband is also aged 26. Which of the following options is the MOST APPROPRIATE advice?
A. The best time to have sex is when you have preovulatory mucus, which is that increased watery clear discharge at midcycle
B. Use a daily temperature chart to check you are ovulating, as the temperature rises about 0.5O C after normal ovulation
C. Use an LH urine kit to determine when you are ovulating, and thus the best time to have sex
D. Confine sex to your most fertile period, which is likely to be between Days 12-16
E. Have sex daily or every other day if possible for the 5 days leading up to and including the day of ovulation which is likely between days 10-16 in a regular 28 day cycle
F. When you have the mid-cycle ovulation discomfort, you are ovulating, and that is the best time to have sex
E. Have sex daily or every other day if possible for the 5 days leading up to and including the day of ovulation which is likely between days 10-16 in a regular 28 day cycle
You are a trainee intern in general practice with Penny, a 19 year old G0P0 Pākehā woman who has just advised you that this will be the last prescription for the combined oral contraceptive pill. She has been using the pill for four years, and is stopping as she wishes to become pregnant. Addressing which of the following lifestyle issues would MOST BENEFIT her fertility?
A. Her BMI of 29.4
B. Her weekly use of marijuana
C. Her caffeine intake of 5+ cups of coffee per day
D. Her smoking of 20 cigarettes per day
E. Her alcohol intake of 3 units per week
D. Her smoking of 20 cigarettes per day
You are a trainee intern in general practice with Hannah, a 28 year old G0P0 Pākehā woman who presents with her husband as they haven’t conceived six months after she stopped the pill. She started on the pill at age 16 for irregular periods. Since stopping the pill Hannah has had two periods; the last was two months ago. A home pregnancy test was negative. Apart from her weight (BMI 29 kg/m2), there are no abnormalities on examination, and particularly no hirsutism or acne. You wonder if this could be PCOS and arrange several investigations. Which of the following options would be MOST LIKELY to help confirm this diagnosis?
A. FSH
B. Oestradiol
C. A transvaginal pelvic ultrasound
D. Serum progesterone
E. Insulin
F. Testosterone
G. Prolactin
C. A transvaginal pelvic ultrasound
You are a trainee intern in general practice with Lucy, a 28 year old G0P0 NZ European woman who presents with her husband as they haven’t yet conceived 12 months after she stopped the oral contraceptive pill. She started on the pill for irregular periods at age 16. She did not have acne. Since stopping the pill she has had two periods; the last was two months ago. A home pregnancy test was negative. Apart from her weight (BMI 29 kg/m2), there are no abnormalities on examination, and particularly no hirsutism or acne. You arrange an ultrasound scan and are reviewing the result with her. A representative picture of each ovary is shown.
ovaries
[2 ULTRASOUND SCANS OF OVARIES WITH]
From the following options, which is her MOST LIKELY diagnosis?
A. PCO (Polycystic Ovaries)
B. Bilateral ovarian serous cystadenomas
C. PCOS (Polycystic Ovarian Syndrome)
D. Normal ovaries
E. Functional ovarian cysts
F. Bilateral complex ovarian cysts
C. PCOS (Polycystic Ovarian Syndrome)
You are a trainee intern in general practice seeing Holly, a 37 year old nulliparous Pākehā woman who hasn’t conceived since she stopped the pill one year ago. Holly has a BMI of 24. She has regular periods, 5/28, with slight spotting for 2-3 days before the heavier loss. She also has significantly increasing pain before her periods over the past year, and sometimes pelvic pain on her right side at midcycle. Holly has no dyspareunia, or pain with bowel motions. She has never had an STI and all smear tests are normal. Her partner aged 38, has good health, and has two children from a previous relationship. The youngest is aged 5 years. Based on this history, which of the following is the MOST LIKELY cause of her infertility?
A. (PCOS) Polycystic ovary syndrome
B. Pelvic Inflammatory Disease
C. Endometriosis
D. Endometrial hyperplasia
E. Male factor
C. Endometriosis
