Fertility

Question 1

What are some male and female factors you can ask on history to ascertain the cause of infertility?

Answer 1

Male:

• age
• past fertility
• development
• sexual function
• testicular: trauma, descent, torsion
• med/surg/psych
• family
• vastectomy

Female:

• age
• development
• menstrual cycle
• pregnancies
• time trying to concieve
• stigmata endometriosis
• sexual patterns
• FHx

Question 2

Female Fertility problems related to anovulation and how you categorise them?

Answer 2

Obesity and PCOS:

• AFC >20
• oligomenorrhea
• hyperandrogenism

FSH low: HPO dysregulation

• Causes:
  
  • low weight
  • stress
  • pituitary tumour
  • infiltrative (sarcoid, haemochromatosis)
  • high physical activity
  • genetic e.g. Kallmann

lifestyle and ovulation induction

FSH high = ovarian failure

• iatrogenic - chemo/radiation
• autoimmune = SLE, RA
• Genetic = FXS, XO, FHx
• physiologic = age >45

treatment - oocyte donation

Question 3

What are some anatomical causes of infertility?

Answer 3

• congenital
  
  • mullerian abnormality (look for renal abnormalities) – not formed properly
  • disorders of sex development DSD - intersex.
• acquired
  
  • compromised tubal patency (STIs, TB)
  • endometriosis (conservative tx prevent infertility later, prevent progression, increasing dysmenorrhea - pill (don’t ovulate)).
  • fibroids - might distort uterus, myomectomy to concieve
• Ix:
  
  • renal imaging - renal imaging.
    
    • menonephric ducts form at same time.
  • STI screen
  • pelvic US
  • MRI etc…

Question 4

What are some egg factors that can cause infertility?

Answer 4

• age related decreased ovarian function
  
  • egg repairs DNA damage in sperm
  • egg number reduces with age
  • anuploidy increases with increased age
• AMN (anti-mullerian hormone) = a biomarker of ovarian reserve

Question 5

WHat are some male causes of infertility? What of these causes are modifiable?

Answer 5

• Causes:
  
  • azoospermia
  • oligozoospermia
  • motlity
  • morphology
  • aetiology:
    
    • modifiable
      
      • hypogonadism
      • smoking
      • vasectomy
      • varicocele (jury’s out)
      • anabolic steroid abuse = steroids will shut down sperm
    • genetic
      
      • Klinefelter’s
      • CF
      • Y chromosome (azoospermia factor) AZF when mutated. - AZF A/B

Question 6

What is IVF? What do you do?

Answer 6

In-vitro fertilization - manipulate physiology:

• super-ovulatory dose of FSH - get them all to grow together.
  
  • AMH to test ovulatory reserve
• Antagonist cycle: GnRH agonist (start of cycle and empty tank, flare - release endogenous) or antagonist (blocks at hypothalamus)
  
  • get without hyperstimulation syndrome
    
    • PCOS
    • freezing eggs
  • antidote to antagonist - agonist trigger. 23hr half life.
• collect oocytes
• embryo culture
• embryo transfer
• vitrificaiton (into a glass)

Question 7

What is Ovarian hyperstimulation syndrome? OHSS - why doesn’t it happen anymore?

Answer 7

• iatrogenic complication triggered by HCG given to support luteal phase.
  
  • Will resolve in women who don’t get pregnant but if they do it gets worse.
  • RAAS - third spacing of fluid + VEGF
    
    • bleeds
    • clots
    • effusions
  • completely avoidable with appropriate fertility specialists.

Question 8

What is PGD?

Answer 8

Preimplantation genetic diagnosis:

• trophectoderm (D5 embryo)/blastomere (D3 embyro) sampling for genetic analysis.
  
  • mendelian syndromes
    
    • HD
    • neurofibromatosis
  • screening for aneuloidy