Fertility

Question 1

What is the distinction between primary and secondary infertility?

Answer 1

PRIMARY = when neither partner has ever conceived
SECONDARY = when one or both partners have conceived before (either together or with a different partner

Question 2

On average, how many couples will conceive after 12-24 months of unprotected intercourse?

Answer 2

-85% within 12 months
-92% within 24 months
-Infertility = failure to conceive after 12 months of regular unprotected sex

Question 3

What are the 3 main requirements for conception?

Answer 3

-Ovulation
-Tubal patency
-Healthy sperm

Question 4

What are the common causes of infertility?

Answer 4

-Sperm problems (30%)
-Ovulation problems (25%)
-Tubal problems (15%)
-Uterine problems (10%) eg bicornate uterus, polyps, adhesions
-Unexplained (20%)
NB 40% of couples will have mixed male and female causes

Question 5

What are the different possible types of sperm problems that can cause infertility?

Answer 5

-Azoospermia = absent spermatozoa
-Oligospermia = few spermatozoa
-Teratozoospermia = excess numbers of abnormal sperm
-Asthenzoospermia = large proportion of immotile sperm
-Can be caused by trauma, previous chemotherapy, anabolic steroid use, CF, hypogonadism, but commonly idiopathic

Question 6

How can male factor infertility be managed?

Answer 6

-Sperm ejaculate sample (if abnormal, repeat in 3 months)
-If sperm present in sample:
–ICSI = inject sperm directly into egg
-If sperm not present in sample:
–Surgical sperm retrieval / PSA = sperm collected from epididymis, blockage along vas deferens
–Surgical correction = resolving blockage in vas deferens
–Intra-uterine / donor sperm insemmination = injection into uterus

Question 7

What are the three main causes of anovulatory infertility?

Answer 7

Group I - hypothalamic / pituitary failure
Group II - PCOS (90%)
Group III - premature ovarian insufficiency

Question 8

What are some causes of hypothalamic / pituitary failure infertility?

Answer 8

-Weight loss / systemic illness
-Anorexia nervosa
-Pituitary surgery or irradiation
-Inflammatory causes eg TB, sarcoidosis
-Sheehan’s (postpartum pituitary necrosis)
-Congenital eg Kallmann’s syndrome
-Hyperprolactinaemia

Question 9

What changes to hormone levels would you expect in hypothalamic / pituitary failure?

Answer 9

FSH - very low
LH - very low
E2 - very low
leads to peri-menopausal symptoms

Question 10

How can you manage hypothalamic / pituitary failure infertility?

Answer 10

-Correct weight / underlying health problems
-Discourage extreme exercise
-Gonadotrophins to induce induction once a healthy weight etc

Question 11

How does PCOS cause anovulatory infertility?

Answer 11

-Increased GnRH –> increased LH –> increased theca cell testosterone secretion
-Reduced sex hormone-binding globulin levels
-Arrest in folliculogenesis and ovulation

Question 12

What changes to hormone levels would would expect in PCOS?

Answer 12

FSH - low/normal
LH - high / normal
E2 - high / normal

Question 13

What is premature ovarian insufficiency and how is it diagnosed?

Answer 13

-Loss of ovarian activity before the age of 40
-Oligo/amenorrhoea for at lest 4 months
-Elevated FSH (>25) on two occasions >4 weeks apart (measured on day 1-3 of menstrual cycle)

Question 14

What changes to hormone levels would you expect to see in POI?

Answer 14

FSH - very high
LH - high
E2 - high

Question 15

What can cause POI and how can it be managed?

Answer 15

-Turner’s syndrome (45X)
-Fragile X synrome
-Addison’s disease, thyroid pathology
-Hyperprolactinaemia
MANAGEMENT
-Egg donation
-HRT (E2 and P4)

Question 16

What investigations can be done to assess tubal patency?

Answer 16

-Hysterosalpingogram
-Laparoscopy and dye test

Question 17

What can cause tubal factor infertility and how can it be managed?

Answer 17

CAUSES
-PID
-Untreated STIs
-Endometriosis
-Adhesions
MANAGEMENT
-Tubal cannulation (during hysterosalpingogram)
-Lapasocopic removal of adhesions or endometriosis
-IVF

Question 18

When is the ‘fertile window’?

Answer 18

-Egg is viable for 24h after ovulation
-Sperm are viable in uterus for 5 days
-Ovulation normally occurs on day 14-16 of 28-day cycle
-So fertile window = day 9-17

Question 19

What pre-conceptual advice can be given to couples?

Answer 19

BOTH
-Stop smoking
-Little / no alcohol
-Optimise BMI
-Stop recreational drug use, avoid occupational hazards, STI screen
WOMEN
-Up to date smear
-?Reduce caffeine intake?
-Take folic acid and vitamin D supplements
MEN
-Avoid elevated scrotal temperature

Question 20

In summary, what investigations should be done for a couple presenting with infertility?

Answer 20

-HPO axis assessment (FSH, LH, oestrogen, testosterone, progestogen, prolactin)
-Semen analysis (count >15 million/ml, motility >40%, normal formation >4%)
-Assess anatomy (USS)
-Assess tubal patency

Question 21

What are the different assisted reproduction options?

Answer 21

IUI = insertion of selected seminal fluid into uterus around time of ovulation
–Ideal for asthenzoospermia
ICSI = single sperm injected directly into single egg
–Ideal for oligospermia
IVF = egg and sperm are fertilised lab and embryo is then implanted into uterus

Question 22

What is the best way to test for ovulation?

Answer 22

-Day 21 progesterone level

Question 23

What causes OHSS and what are its symptoms?

Answer 23

-Increase in vascular endothelial growth factor release from granulose cells of follicles
-Increased vascular permeability –> fluid leakage
-LH/FSH therapy for ovarian stimulation requires hCG injection 36h before oocyte collection –> triggers OHSS
SYMPTOMS
-Oedema
-Ascites
-Abdo pain, N+V
-Hypovolaemia / hypotension
-Associated with raised renin level due to activation of the RAS

Question 24

Who is most at risk of OHSS?

Answer 24

-Younger age
-Low BMI
-Raised AMH
-High follicle count
-PCOS
-Raised oestrogen levels during ovarian stimulation