Female Infertility

Question 1

What is the definition of subfertility?

Answer 1

• Regular, unprotected intercourse for a period of 12 months without a pregnancy is considered to be infertile
• Affects 10-15% of couples
• It is seldom absolute

Primary subfertility = pregnancy has never been achieved before
Secondary subfertility = previous pregnancy, however it may have ended in miscarriage or ectopic loss

Question 2

What are the key requirements of conception that can fail?

Answer 2

○ Ovulation
○ Oocyte transport along the Fallopian tubes
○ Timed coital delivery of sperm
○ Cervical mucous secretion and receptivity
○ Sperm motility to penetrate cervical mucous and reach the Fallopian tubes
○ Fertilisation
○ Uterine/endometrial receptivity for implantation

Question 3

What are the main causes of subfertility?

Answer 3

unexplained 28%
Male factor 23%
Ovulatory dysufnction 18%
Tubal damage 14%
endometriosis
coital dysfunction
abnormal cervical mucous

Question 4

How do we investigate male infertility?

Answer 4

To assess the male factor, a semen analysis is performed and sperm are studied for motility, concentration, morphology, signs of infection and presence of anti-sperm antibodies.

Question 5

How do we investigate female infertility?

Answer 5

Ovulatory disorders can be suspected on history alone
○ Anovulatory woman will require a full endocrinologic work-up to determine the basis of ovulatory dysfunction
Ovulation can be confirmed most easily by luteal phase progesterone determination
Pelvic and uterine anatomy and tubal patency are assessed by ultrasound, hysterosalpingography or even laparoscopy/hysteroscopy

Question 6

What does the ultrasound assessment of the uterus include for subfertility?

Answer 6

Evaluation of size as an indirect measure of hormonal activity
Look for fibroids or congenital anomalies

Question 7

What does the ultrasound assessment of the cervix include for subfertility?

Answer 7

Evaluate length and cervical mucous.

Look for cysts

Question 8

What does the ultrasound assessment of the endometrium include for subfertility?

Answer 8

Evaluate thickness as an indirect measure of hormonal activity.
Look for polyps, adhesions

Question 9

What does the ultrasound assessment of the adnexae include for subfertility?

Answer 9

Look for hydrosalpinx and para-ovarian cysts

Question 10

What does the ultrasound assessment of the ovaries include for subfertility?

Answer 10

Measure size.
Look for presence of immature follicles (<10mm), follicular development, evidence of ovulation, PCO, dysfunctional ovulation

Question 11

What is ovarian stimulation?

Answer 11

In a natural cycle, developing dominant follicles varies from zero to two
In a stimulated cycle, aim is to achieve a single ovulation or to produce a cohort of oocytes for artificial reproduction
○ Uses exogenous agents to stimulate growth and development of follicles within the ovary
Enhancement of the process of follicular rupture and release of an oocyte

Question 12

What are the three steps of assisted reproduction?

Answer 12

Ovarian stimulation
Preparation of a suspension of motile sperm
approximation of male and female gametes

Question 13

What are the main types of assistive reproduction?

Answer 13

Intrauterine insemination
Embryo transfer
Intracytoplasmic sperm injection

Question 14

What is ultrasound used for in assisted reproduciton?

Answer 14

Ultrasound is used to track the ovarian response to the ovarian stimulation protocol, to guide oocyte retrieval and possibly to observe embryo transfer
Ultrasound is performed 4-6 weeks after oocyte retrieval to confirm pregnancy location and determine the number of viable embryos
Assess uterine receptivity = endometrial thickness
<4mm is not really viable

Question 15

What are the main risks of assisted reproduction?

Answer 15

○ Ovarian hyperstimulation
○ Ectopic pregnancy
○ Multiple pregnancy