Fertility

Question 1

Definitions:

1. Subfertility
2. Primary subfertility
3. Secondary subfertility

Answer 1

1. X conception after 1y regular, unprotected intercourse.
2. female never conceived.
3. previous conception(includes miscarriage and termination)

Question 2

Causes

Answer 2

1. Anovulation(30%)
2. Male(25%)
3. Tubal(25%)
4. Unexplained(30%) -commonly implantation prob
5. coital(5%), cervical(<5%)

Question 3

Causes of anovulation

Answer 3

1. Hypothalamic
   - Hypothalamic hypogonadism
   - Kallman’s syndrome
2. Pituitary causes
   - Hyperprolactinaemia due to adenomas/hyperplasia/assoc w PCOS, hypothyroidism,antipsychotics.
   - Tx with bromocriptin/cabergoline
   - Sheehan’s syndrome
3. Ovarian causes
   - Premature ovarian failure. Gives raised FSH and LH. Tx with HRT/COCP for bone protection
4. Thyroid disease

Question 4

WHO reference values for semen analysis

Answer 4

Volume     >1.5 mL
Sperm count  >15 million/mL
Progressive motility  >32%
Oligospermia  <15 million/mL
Severe "  <5 million/mL
Morphology >4%

Question 5

Common causes male subfertility:

Answer 5

1. Idiopathic
2. Drugs. Alcohol, smoking, anabolic steroids, solvents.
3. Varicocoele. about 25% infertile man
4. Antisperm Antibodies. about 5% infertile man
5. Infections
6. Congenital absence of vas(usually CF assoc)
7. Hypothalamic prob, Kallman’s, HyperPRL
8. Retrograde ejaculation

Question 6

Investigations

Answer 6

1. Semen analysis, repeat after 12 w if abn
2. If azoospermia, blood tests: FSH, LH, testosterone, PRL, TSH.
   - high FSH and LH but low testosterone indicates primary testicular failure(possibly due to cyptorchidism, surgery, radiochemotx)
3. Azoospermia+absent vas: test for CF

Question 7

Management

Answer 7

1. Lifestyle advice
2. Mild to moderate oligospermia, IUI.
3. Moderate to Severe oligospermia, IVF w/wout ICSI.
4. Azoospermia
   - check for vas deferens
   - karyotype for CF, hormone profile
   - Surgical Sperm Retrieval then IVF+ICSI/donor insemination

Question 8

Tubal damage

1. Causes
2. Investigations
3. Treatments

Answer 8

1. PID. Infection(STI, IUD insertion), adhesions
2. Hysteroscopy+laparoscopy and dye test. HSG/US with contrast
3. Laparoscopic adhesiolysis and salpingostomy. IVF

Question 9

Indications for assisted conception

Answer 9

1. other methods failed.
2. Endometriosis
3. Unexplained subfertility
4. Male subfertility
5. Genetic disorders
6. Tubal blockage

Question 10

IVF success predictors

Answer 10

1. female age
2. no. of previous tx. cycles
3. prev pregnancy history
4. BMI 19-30
5. Lifestyle: alcohol, smoking, caffeine

Question 11

IVF access criteria

Answer 11

1. <40y, X conceive after 2y regular, unprotected intercourse OR 12 cycles artificial insemination.
2. never had IVF
3. No evidence of low ovarian reserve.

Question 12

Procedures

Answer 12

1. Down regulation with GnRH agonists.
2. Controlled ovarian stimulation with urinary/recombinant gonadotrophins. usually FSH.
3. Triggering ovulation with urinary/recombinant hCG
4. oocyte and sperm retrieval
5. US-guided embryo transfer.
6. Luteal phase support w progesterone not beyond 8w gestation.

Question 13

ICSI

Answer 13

severe deficits in semen quality; obstructive/non-obstructive azoospermia; previous IVF tx failed

Question 14

Donor insemination

Answer 14

Severe deficit in semen quality; obstructive/non-obstructive azoospermia; high risk transmitting genetic disorder; high risk transmitting infectious disease to offspring/woman; severe rhesus isoimmunisation.

Question 15

Oocyte donation

Answer 15

Premature ovarian failure; gonadal dysgenesis; bilat. oophorectomy; tx with radio/chemotx; certain cases of IVF failure