Fertility

Question 1

What is infertility?

Answer 1

Not conceiving after trying to have regular (2/3 x a week) unprotected sex for 1 year

Question 2

What are the main 2 categories to think about when working out what could be reducing female fertility?

What are some other causes?

Answer 2

Ovulatory disorders
Tubal damage

Other - cervical mucus dysfunction, fibroids that distort uterine cavity, previous cervical surgery, chronic debilitating disease

Question 3

What can cause tubal damage and therefore lead to infertility?

Answer 3

Adhesions: PID and endometriosis

Previous sterilisation

Question 4

What are the types of ovulatory disorder and what blood results differentiate them?

Answer 4

1 - Hypothalmic pituitary failure
- low gonadotrophins and oestrogen

2 - HPO failure e.g. PCOS (85%)
- Raised LH, low progesterone

3 - Ovarian failure (5%)
- high gonadotrophins, low oestrogen

Question 5

What are the causes of hypothalamic pituitary failure

Answer 5

Hypothyroid (decreases FSH and LH)

prolactinoma (inhibits GnRH so decreased LH and FSH)

Question 6

What male factors can lead to infertility?

Answer 6

Genetic dysfunction
Varicocoele (raises testicular temperature)
Testicular cancer treatment
Trauma
Pituitary dysfunction
Hypospadias
Erection/ejaculatory failure

Question 7

What general factors can lead to infertility?

Answer 7

Age
Stress
Obesity
Smoking
Alcohol
Anabolic steroids
Recreational drugs
Tight fitting clothing

Question 8

What would you ask in a history of infertility?

Answer 8

Previous pregnancies/fathered any children
Length of time trying
Type of contraception previously used and when stopped
Coital freq. 
Previous STI's, fertility treatment
General health - including BMI
Drug Hx
Female - menstrual Hx, OBGYN hx
Male - mumps or measles

Question 9

When would you request investigations for infertility?

Answer 9

After 1 year of regular intercourse

Question 10

How would you investigate a female with suspected infertility?

Answer 10

Progesterone on day 21 (Mid-luteal phase)
Oestrogen, LH and FSH on day 2
Chlamydia screen

+/-Thyroid function
+/-Prolactin

Question 11

How would you investigate a male with suspected infertility?

Answer 11

Semen analysis - masterbation after 2-7 days abstinence of sexual activity
1 abnormal test = repeat
2 abnormal tests = refer

Chlamydia screen

Question 12

When would you refer someone to secondary care with suspected infertility?

Answer 12

1 year regular intercourse

+ all investigations in primary care come back as normal

Question 13

What can be done in secondary care to investigate infertility?

Answer 13

Pelvic USS
Tubal patency testing - hysterosalpingography or diagnostic laparoscopy

In depth sperm analysis

Question 14

How can hypothalamic-pituitary infertility be managed medically?

Answer 14

Gain weight
Reduce exercise
Pulsatile gonadotrophins
Treat hypothyroidism

Question 15

How can HPO disorder infertility be managed?

Answer 15

Clomifene citrate

+/- metformin

Question 16

How can hyperprolactinaemia induced infertility be managed?

Answer 16

Dopamine agonist - bromocriptine

Question 17

How can male hypogonadotrophic hypogonadism be managed?

Answer 17

Gonadotrophins

Question 18

How does clomifene citrate work?

Answer 18

Anti-oestrogen –> inhibit negative feedback effect that oestrogen has on hypothalamic pituitary axis

Question 19

What are the ADR’s and CI’s of clomifene citrate?

Answer 19

CI - Ovarian cyst, unexplained vaginal bleed

ADR - hot flush, bloating, head and abdo pain, N&V, breast tenderness, menstrual irregularities

Question 20

How can infertility be managed surgically?

Answer 20

Tubal catheterisation or cannulation
Surgical ablation and resection of endometriosis
Surgical correction of any epididymal blockage

Question 21

What are the methods of assisted conception?

Answer 21

Intrauterine insemination
- sperm into uterus
Donor insemination
- donor sperm into uterus

In vitro fertilisation
- retrieve egg and sperm, mix and incubate, put embryo into uterus
Intracytoplasmic sperm injection
- as above but sperm injected directly into egg
Oocyte donation
- IVF but with donor egg

Question 22

When is donor insemination used?

Answer 22

Man has no sperm
Man has an infectious disease - HIV
Man has a genetic conditions
No male partner

Question 23

What are the main complications of artificial conception?

Answer 23

Ovarian hyperstimulation syndrome
Ectopic
Pelvic infection
Multiple pregnancy

Question 24

How does ovarian hyperstimulation present?

Answer 24

Due to fluid loss in third space (mainly abdo):
Bloating
Abdominal pain
N&V
Diarrhoea
Oliguria
Ascites
SOB

Question 25

How is ovarian hyperstimulation syndrome managed?

Answer 25

Supportive - fluids and analgesia

DVT prophylaxis