Fertility

Question 1

How many couples are subfertile?

Answer 1

1/6 couples

Question 2

Definition and causes of infertility

Answer 2

No chance of conceiving:
•	Tubular blockage after PID
•	Premature ovarian failure
•	No sperm
•	Ovaries removed

Question 3

Diagnosis of subfertility?

Answer 3

No conception after 12 months of unprotected intercourse

Question 4

What is the chance of spontaneous conception each cycle?

Answer 4

20%

Question 5

What investigations are done for subfertile couples?

Answer 5

• Is there an egg? (mid luteal phase around day 21 progesterone) LH and FSH peak 24hrs before ovulation. USS of follicle growth.
• Is there a sperm? (semen analysis)
• Can they meet? (tubal patency test)

Question 6

Why might someone not ovulate? (classifications)

Answer 6

WHO I: Hypothalamus problem (FSH and oestrogen low) hypogonadotropic and hypo-oestrogenic anovulation
WHO II: normogonadotropic, normo-oestrogenic (PCOS)
WHO III: hypergonadotropic anovulation, FSH up, oestrogen low

Question 7

Treatment of WHO I anovulation

Answer 7

Hypothalamus doesn’t work

Give pump of Gn-RH or give FSH/LH

Question 8

Treatment of WHO II anovulation

Answer 8

Clomiphene anti-oestrogen, tricks pituitary into producing more FSH-> induces ovulation
Can supplement FSH/LH in cyclical way
Ovarian drilling

Question 9

SE of FSH/LH supplementation in WHO II anovulation?

Answer 9

Multiple pregnancies (20%)
Ovarian hyperstimulation syndrome

Question 10

Treatment of WHO III anovulation

Answer 10

Ovaries have given up
No eggs to can offer donor oocytes
Can try IVF as maximum stimulation may work

Question 11

Summarise the hypothalamopituitary axis for female sex hormones

Answer 11

Hypothalamus-> GnRH (pulsatile)
GnRH travels to pituitary
Pituitary-> LH +FSH
LH-> corpus luteum to produce progesterone & oestrogen, relax, inhibin
LH-> ovulation
FSH-> follicle development, oestrogen and inhibin

Question 12

Role of relaxin

Answer 12

Inhibits contractions of uterine smooth muscle

In labour, dilates cervical canal

Question 13

Role of inhibin

Answer 13

Inhibits FSH (and LH) production

Question 14

Role of oestrogen

Answer 14

Promotes development of female reproductive structures, feminine secondary sex characteristics and breasts
Increases protein anabolism
Decreases blood cholesterol
Inhibits GnRH, FSH& LH

Question 15

How do you treat hyperprolactinaemia?

Answer 15

Dopamine agonist
Bromocroptine, cabergoline
Stop antipsychotic treatment

Question 16

What needs to be true for semen analysis to be normal

Answer 16

Need at least 15million spermatozoa per ml of semen to be normal.
Motility 40% or more, morphology normal in more than 4% of them.

Question 17

Causes of poor sperm count

Answer 17

• Infection (mumps, STDs)
• Trauma (surgery for inguinal hernia? Testicular torsion? TURP?)
• Drugs (steroid use, cannabis, cocaine, sulfaslazine, TCAs)
• Radiotherapy
• Varicocele
• Congenital (undescended testes, CF)
Increased testicular temperature (eg lorry drivers)
Working w/heavy metals and solvents

Question 18

How is tubal patency assessed?

Answer 18

• Chlamydia serology
• Contrast ultrasound (HyCoSy) (saline test from catheter inside uterus, then use radiolucent gel)
• Hysterosalpingogram (X-ray with dye)
• Diagnostic laparoscopy (methylene blue) Gold standare for diagnosis but operative risk. Can be therapeutic (adhesions, endometriosis, fibroid resection)

Question 19

Differences between primary and secondary infertility

Answer 19

Primary infertility: Never conceived

Secondary infertility: Never given birth. Possible ectopic pregnancy, miscarriage.

Question 20

Causes (%) of female infertility

Answer 20

Ovulatory disorder (PCOS) (40%)
Tubal factor (40%)
Unexplained (15%)
Uterine factor (5%)

Question 21

Define IUI

When is it used?

Answer 21

Intrauterine insemination
Can be used in mild sperm defect or unexplained infertility.
Can be used in same sex couples.
Semen specimen is centrifuged and washed. Brought together at the right time. Can be done by monitoring a natural cycle or in a stimulated cycle. Can enhance cycle with clomiphene.

Question 22

What can be done to improve tubal patency

Answer 22

Tubal surgery for:
Adhesions (previous chlamydia)
Blocked/damaged fallopian tube or distorted by large fibroids.
Reversal of sterilisation

Question 23

When is IVF used?

Answer 23

• Tubal blockage
• After unsuccessful OI or IUI
• Severe male factor
• After 3 yrs unexplained infertility

Question 24

What are the added options for IVF?

Answer 24

• Operative sperm removal from testes-> intracytoplasmic sperm injection
• Egg donation (if no eggs at all)
• Surrogacy (absent uterus)
Also pre-implant genetic diagnosis

Question 25

What is involved in the process of IVF?

Answer 25

• Ovarian stimulation
• Follicle aspiration
• Fertilisation in vitro (intracytoplasmic injection of sperm or incubation with thousands of sperm)
• Embryo development (incubation)
• Embryo transfer into uterus (single embryo)
• Implantation into the uterine wall is the limiting step

Question 26

Causes of tubal blockage

Answer 26

PID (10% risk w/1 episode, 50% with 3)
Endometriosis (scarring)
Previous surgery
Previous ectopic pregnancy

Question 27

What can reduce a woman’s number of ovulatory cycles?

Answer 27

Low BMI (anorexia.hyperthyroid)
Regular NSAIDs
Cannabis
PCOS
Hyperprolactinaemia