Fertility

Question 1

How do you confirm ovulation?

Answer 1

Take the serum progesterone level 7 days prior to the expected next period

> 30 nmol/l indicates ovualtion

Question 2

counselling points fertility

Answer 2

folic acid
aim for BMI 20-25
advise regular sexual intercourse every 2 to 3 days
smoking/drinking advice

Question 3

Basic fertility investigations

Answer 3

semen analysis
serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21.

Question 4

When do you initiate investigations for infertility

Answer 4

After 12 months of trying

After 6 months if >35

Question 5

Advice for couples trying to conceive

Answer 5

The woman should be taking 400mcg folic acid daily
Aim for a healthy BMI
Avoid smoking and drinking excessive alcohol
Reduce stress as this may negatively affect libido and the relationship
Aim for intercourse every 2 – 3 days
Avoid timing intercourse

Question 6

Initial investigations infertility

Answer 6

BMI
chlamydia screening
Semen analysis
Female hormone testing: FSH, LH, Progesterone, AMH, prolactin
Rubella immunity testing

Question 7

When is LH and FSH tested - fertility

Answer 7

day 2 to 5 of the cycle

Question 8

When is progesterone measured - fertility

Answer 8

7 days before end of cycle

Question 9

What does FSH indicate - fertility

Answer 9

High FSH suggests poor ovarian reserve (the number of follicles that the woman has left in her ovaries). The pituitary gland is producing extra FSH in an attempt to stimulate follicular development.

Question 10

What does LH indicate- fertility?

Answer 10

high could indicate PCOS

Question 11

what does progesterone indicate - fertility

Answer 11

A rise in progesterone on day 21 indicates that ovulation has occurred, and the corpus luteum has formed and started secreting progesterone.

Question 12

What does AMH indicate- fertility

Answer 12

It is released by the granulosa cells in the follicles and falls as the eggs are depleted. A high level indicates a good ovarian reserve.

Question 13

Secondary care investigations

Answer 13

Ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus

Hysterosalpingogram to look at the patency of the fallopian tubes

Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis

Question 14

Management of anovulation

Answer 14

Weight loss for overweight patients with PCOS can restore ovulation

Clomifene may be used to stimulate ovulation

Letrozole may be used instead of clomifene to stimulate ovulation (aromatase inhibitor with anti-oestrogen effects)

Gonadotropins may be used to stimulate ovulation in women resistant to clomifene

Ovarian drilling may be used in polycystic ovarian syndrome

Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)

Question 15

How does clomifene work

Answer 15

Clomifene is an anti-oestrogen (a selective oestrogen receptor modulator). It is given on days 2 to 6 of the menstrual cycle. It stops the negative feedback of oestrogen on the hypothalamus, resulting in a greater release of GnRH and subsequently FSH and LH.

Question 16

Define oligospermia

Answer 16

Mild oligospermia (10 to 15 million / ml)
Moderate oligospermia (5 to 10 million / ml)
Severe oligospermia (less than 5 million / ml)

Question 17

Instructions for providing a sperm sample

Answer 17

Abstain from ejaculation for at least 3 days and at most 7 days
Avoid hot baths, sauna and tight underwear during the lead up to providing a sample
Attempt to catch the full sample
Deliver the sample to the lab within 1 hour of ejaculation
Keep the sample warm (e.g. in underwear) before delivery

Question 18

Pre-testicular causes of male factor infertility

Answer 18

Testosterone is necessary for sperm creation. The hypothalamo-pituitary-gonadal axis controls testosterone. Hypogonadotrophic hypogonadism (low LH and FSH resulting in low testosterone), can be due to:

Pathology of the pituitary gland or hypothalamus
Suppression due to stress, chronic conditions or hyperprolactinaemia
Kallman syndrome

Question 19

Testicular causes of male factor infertility

Answer 19

Testicular damage from:

Mumps
Undescended testes
Trauma
Radiotherapy
Chemotherapy
Cancer

Genetic or congenital disorders that result in defective or absent sperm production, such as:

Klinefelter syndrome
Y chromosome deletions
Sertoli cell-only syndrome
Anorchia (absent testes)

Question 20

Post testicular causes of male factor infertility

Answer 20

Obstruction preventing sperm being ejaculated can be caused by:

Damage to the testicle or vas deferens from trauma, surgery or cancer
Ejaculatory duct obstruction
Retrograde ejaculation
Scarring from epididymitis, for example, caused by chlamydia
Absence of the vas deferens (may be associated with cystic fibrosis)
Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)

Question 21

Further investigations after abnormal semen sample identified

Answer 21

Hormonal analysis with LH, FSH and testosterone levels
Genetic testing
Further imaging, such as transrectal ultrasound or MRI
Vasography, which involves injecting contrast into the vas deferens and performing xray to assess for obstruction
Testicular biopsy

Question 22

success rate of IVF

Answer 22

Each attempt has a roughly 25 – 30% success rate at producing a live birth

Question 23

complications IVF

Answer 23

Failure
Multiple pregnancy
Ectopic pregnancy
Ovarian hyperstimulation syndrome

Question 24

Basic IVF process

Answer 24

1. supression of menstrua cycle with GnRH agonists or antagonists
2. ovarian stimulation with FSH
3. hCG trigger injection
4. oocyte collection
5. oocyte insemination
6. culture
7. transfer
8. pregnancy test after 26 days

Question 25

Pathophysiology of ovarian hyperstimulation syndrome

Answer 25

bHCG injections –> stimulation of granulosa cells –> increase in vascular endothelial growth factor (VEGF) –> increased vascualr permeability –> oedema/ascites/hypovolemia

also renin high due to RAAS activation

Question 26

what indicates higher risk for OHSS

Answer 26

Serum oestrogen levels (higher levels indicate a higher risk)

Ultrasound monitor of the follicles (higher number and larger size indicate a higher risk)

Question 27

Features OHSS

Answer 27

Abdominal pain and bloating
Nausea and vomiting
Diarrhoea
Hypotension
Hypovolaemia
Ascites
Pleural effusions
Renal failure
Peritonitis from rupturing follicles releasing blood
Prothrombotic state (risk of DVT and PE)

Question 28

Management OHSS

Answer 28

Oral fluids
Monitoring of urine output
Low molecular weight heparin (to prevent thromboembolism)
Ascitic fluid removal (paracentesis) if required
IV colloids (e.g. human albumin solution)

Question 29

What blood test may be useful in monitoring the amount of fluid in intravascualr space - OHSS

Answer 29

Haematocrit may be monitored to assess the volume of fluid in the intravascular space. Haematocrit is the concentration of red blood cells in the blood. When the haematocrit goes up, this indicates less fluid in the intravascular space, as the blood is becoming more concentrated. Raised haematocrit can indicate dehydration.

Question 30

gold standard to check patency of tubes

Answer 30

laparoscopy and dye