Fertility

Question 1

What are the causes of subfertility?

Answer 1

Anovulation (30%)
Male factor (25%)
Failure of fertilisation (35%)
- Tubule
- Cervical
- Sexual
Unexplained (30%)

> 1 cause present which is why they add up to >100%

Question 2

What are the anovulatory causes of infertility?

Answer 2

PCOS
Endocrine
Ovarian - Turner’s
Tumour

Question 3

PCOS

What is the definition of polycystic ovaries?

Answer 3

> 12 small (2-8mm) follicles within enlarged ovaries (>10ml) on transvaginal sonography (TVS)

Question 4

What is the definition of PCOS?

Answer 4

2 of 3

i. PCO on USS
ii. Irregular periods (>35d apart)
iii. Hiruitism: clinical (acne, excess body hair)/ biochemical (serum testosterone)

Question 5

What are the risk factors for PCOS?

Answer 5

Family History (esp of T2DM)
Obesity
Genetic

Question 6

PCOS

Briefly explain the pathophysiology?

Answer 6

↑ LH + ↑ Insulin resistance - both can cause ↑ androgen
↑ Androgens - inhibit ovulation
↓ Sex hormone binding globulin - low in PCOS

Disruption of folliculogenesis - no ovulation
Hirsutism

Question 7

PCOS

Clinical features

Answer 7

PCO - asymptomatic

PCOS

Oligo/amenorrhoea
Hirsutism
Acne
Obesity

Question 8

PCOS

Risks and complications

Answer 8

Short term:
Infertility, obesity, miscarriage

Long term:
T2DM (insulin resistance lol), gestational diabetes, endometrial cancer (oestrogen could be normal or ↑ but there is no progesterone to limit it)

Question 9

PCOS

Investigations?

Answer 9

Mid-luteal phase progesterone - low in PCOS
Urine LH testing - high

Serum and free testosterone - normal - slightly raised
If wildy high, then consider something else

TVS - PCOs

Have to run other blood tests to rule out other options

Question 10

PCOS and to rule out everything else

More investigations?

Answer 10

Blood

LH/FSH - in PCOS the LH:FSH ratio will ↑ (3:1), LH is high but FSH is normal. In prem ovarian failure, both levels will ↑ but hypothalamic ↓

Prolactin - ↑ would indicate a prolactinoma
TSH - ↑ Hypothyroid
17-hydroxyprogesterone - CAH

Fasting lipids / glucose - Diabetes screen

Specific Ix

CT/MRI - look at pituitary
Oestradiol, insulin - ↓ in Ovarian failure

Question 11

Management of PCOS

Answer 11

Refer to gynae/endo

In general, management is mainly for the complications

•	Insulin resistance:
Weight loss (diet & exercise), metformin

• Oligomenorrhoea + contraceptive wanted - also protective of endometrial cancer later down the line
COCP, POP, mirena IUS

• Hirsutism:
Dianette (co-cyprindiol) (cyproterone acetate + oestriol), spironolactone, eflornithine facial cream

Question 12

Management of PCOS

Fertility

Answer 12

o 1L: clomifene (given at d2-6, monitor by TVS; ↑ dose if no follicles, cycle cancellation if ≥3 follicles)
o 2L:
Clomifene + metformin
Gonadotrophins (FSH ± LH daily s/c; USS follicular development; hCG/LH injection when follicle ~17mm)
Ovarian diathermy (+ test tubal patency, Rx endometriosis/adhesions)
o 3L: IVF

Question 13

Management of hypothalamic hypogonadism

Fertility

Answer 13

• 1L: ↑ weight
• 2L: Gonadotrophins (if wt normal)
• 3L: IVF

Question 14

Management of prolactinoma

Fertility

Answer 14

• 1L: Bromocriptine/cabergoline
• 2L: Surgery (or if neuro symptoms)
• 3L: IVF

Question 15

Management of premature ovarian failure

Fertility

Answer 15

• IVF + oocyte donation

* HRT + OCP (bone protection)

Question 16

Side effects of ovarian induction

Answer 16

• Multiple pregnancy (clomifene, gonadotrophins)
↑ perinatal complication
• Ovarian hyperstimulation syndrome (OHSS) (gonadotrophins, *in IVF)
o RFs: gonadotrophin stimulation, age <35y, prev OHSS, PCO
o large & painful follicles
o severe – hypovolaemia, electrolyte disturbances, ascites, VTE, pulmonary oedema

Question 17

What % of the time is male fertility the problem?

Answer 17

25%

Question 18

What are the main causes of male infertillity?

Answer 18

Varicocele
Anti-sperm antibodies
Infection
- Commonly epididymitis and mumps orchitis

Testicular abnormalities (Klinefelter’s XXY)
Obstruction (cystic fibrosis – absence of vas deferens)
Hypothalamic, Kallman’s syndrome
Retrograde ejaculation (diabetes, TURP)

Question 19

How would you investigate male infertility?

Answer 19

Sperm analysis + repeat in 12 weeks ( if abnormal)
If normal, then it is NOT male infertility

Examination:

Scrotum - varicele? Inflammation? (orchitis, epididymitis) Vas Deferens present? (CF)

Blood tests for azoospermia

FSH, LH, testosterone

• hypothalamic hypogonadism - ALL ↓
• primary testicular failure - ↑FSH ↑LH, ↓Testosterone

Prolactin, TSH - prolactinoma, thyroid

Karyotype - Klinefelter’s XXY

Question 20

Management of male infertility?

Answer 20

Lifestyle - ↓Drug/chemical exposure, loose clothing, testicular cooling

Hypogonadism - gonadotrophins
Low Sperm Count - intrauterine insemination
Very low sperm count - IVF +-intracytoplasmic sperm injection
0 Sperm - surgical sperm retrieval (if possible), IVF +-intracytoplasmic sperm injection
Donor insemination