Fertility

Question 0

What is primary and secondary infertility?

Answer 0

Primary- female partner has never conceived

Secondary- female partner had previously conceived, even If this resulted in a miscarriage or abortion

Question 1

What is the definition of sub fertility?

Answer 1

A couple is sub fertile if they have had unprotected regular sex for a year and conception has not occurred.

Question 2

What percentage of couples achieve pregnancy after having regular sex (every 2-3 days) without contraception for two years?

Answer 2

90%

Question 3

What are the causes of subfertility?

Answer 3

Tubal disease - 25%
Anovulatory infertility - 30%
Endometriosis - 5%
Male factor - 35%
Unexplained - 15%

Question 4

What lifestyle recommendations can be made to a couple trying to conceive?

Answer 4

Both couples should be engaged

Take folic acid 400mcg (5mg if previous NTD, epileptic or obese)

Stop smoking

Drink minimal alcohol

Question 5

What are the ovarian, pituitary, and hypothalamic causes if an ovulation?

Answer 5

Ovarian:
Poly cystic ovary syndrome
Premature ovarian failure

Pituitary:
Hyperprolactinaemia
Hypopituitarism

Hypothalamic:
Weight loss and over exercise
Systemic illness
Idiopathic hypogonadotrophic hypogonadism
Kallmans syndrome- genetic condition resulting in low level of LH and FSH

Question 6

What is the usual cause of hyperprolactinaemia?

Answer 6

Benign pituitary Adenoma

Also associated with pcos and psychotropic drugs

Question 7

How does hyperprolactinaemia cause subfertility?

Answer 7

Reduces Gnrh release, which reduces LH and FSH and subsequently reduces oestrogen and prevents ovulation

Question 8

How does hyperprolactinaemia present?

Answer 8

Oligomenorrhoea or amenorrhoea, also galactorrhoea

May also have headaches and bilateral hemianopia if due to pituitary adenoma

Question 9

How are is subfertility due to hyperprolactinaemia treated?

Answer 9

Bromocriptine
Cabergoline

Restores ovarian function in 85%

Question 10

What is poly cystic ovary?

Answer 10

USS appearance of the ovary in which greater than 12 small cysts (these are actually follicles) appear on the ovarian epithelium

This is found in 20% of women

Question 11

What criteria must be met for polycystic ovary syndrome?

Answer 11

Oligo and/or amenorrhoea
Polycystic ovaries
Hyper androgenism - hirsutism, acne, obesity

Two out of three of the above

A large proportion develop diabetes later in life
Cardiovascular disease, endometrial and breast carcinoma are also more common

Question 12

How is infertility managed in PCOS?

Answer 12

Weight loss
Chlomiphene citrate- anti oestrogen - increases FSH and LH
Gonadotropins
Laparoscopic ovarian diathermy

Question 13

How is ovulation induced with Gonadotropins?

Answer 13

Purified FSH and LH given in the follicular phase or at regular intervals

This stimulates follicular growth

Once a follicle is the right side for ovulation, ovulation is induced by injecting hcg

Question 14

What are the side effects of ovarian induction?

Answer 14

Multiple pregnancy, as more than one follicle may mature

Ovarian hyper stimulation syndrome - follicles become very large and painful. Vasodilation causes hypovolaemic, ascites, pulmonary oedema, dehydration

Ovarian carcinoma

Question 15

What are the who definitions of normal sperm analysis?

Answer 15

Volume: 2ml
PH 7.2-8.0
Count >15 million ml
Motility > 40%
Morphology >4% normal
Antisperm antibodies - negative

Question 16

What are common causes of abnormal/absent sperm release?

Answer 16

Idiopathic oligispermia and asthenozoospermia - low sperm numbers and motility

Drug exposure - alcohol, smoking, exposure to industrial chemicals

Varicocoele

Antisperm antibodies

Infections, klinefelters, kallmans

Question 17

What does asthenozoospermia mean?

Answer 17

Reduced sperm motility

Question 18

What does oligozoospermia mean?

Answer 18

<15 million/ml sperm

Question 19

What does teratozoospermia mean?

Answer 19

Abnormal sperm morphology

Question 20

How can make factor subfertility be managed?

Answer 20

Lifestyle changes and reduce drug exposure- testicular cooling

Treat causes: ligate varicocoele, treat pituitary disease with gonadotrophins

Surgical spermatozoa retrieval- testicular sperm aspiration or microsurgical sperm aspiration from the epidydimus

Intracytoplasmic sperm injection

Question 21

What are the causes of tubal factor infertility?

Answer 21

PID 
Endometriosis 
Previous surgery - adhesions 
Fibroids
Polyps

Question 22

How is tubal factor infertility investigated?

Answer 22

Hysterosalpingogram in low risk women

Laparoscopy and methylene blue dye test - gold standard

Question 23

How does intrauterine insemination work?

Answer 23

Follicle development tracked by USS
Sperm injected into uterine cavity

Tube should be patent, as ovum needs to travel from ovary to sperm

Birth rate of 15% per stimulated cycle

Question 24

What is the process of IVF?

Answer 24

Ovaries stimulated by FSH and hMG with USS tracking
Hcg triggers oocyte maturation
Eggs aspirated from follicles
Oocytes and sperm incubated overnight
Embryo/s transferred (no more than two) into uterus three to five days later
Progesterone is given as luteal support until 12 weeks

Birth rate around 25% at best

Question 25

What is ICSI?

Answer 25

Intracytoplasmic sperm injection

Injection of one sperm, with a very fine needle, into ooplasma, usually to treat male factor infertility when the sperm are rubbish

Question 26

How does hypogonadotrophic hypogonadism present?

Answer 26

Hypooestrogenic symptoms:
Reduced libido
Vaginal dryness

Low levels of LH and FSH, as anterior pituitary fails to secrete LH and FSH

Question 27

How can ovulation be checked?

Answer 27

Day 21 progesterone - should be >30nmol

Question 28

What are the basic investigations for subfertility?

Answer 28

Semen analysis

Serum progesterone 7 days prior to expected next period