human infertility

Question 1

natural expectation of pregnancy

Answer 1

couple w no issues/underlying problems that would affect their fertility, ~80% pregnant within 1yr

expectation ~90% normal couples should achieve pregnancy by 2yr mark

Question 2

when does decline in female fertility start

Answer 2

after 35yrs and after 40 fertility is very low level

Question 3

problematic effects of age on female fertility

Answer 3

quantity of eggs

decline in quality of eggs - cell division/capacity of egg to perform well in terms of nuclear/genetic material division also declines

Question 4

4 stages of natural conception

Answer 4

ovulation
sperm production
fertilisation
implantation

Question 5

4 stages of natural conception: ovulation

Answer 5

egg produced cyclically

hypothalamo-pituitary-gonodal acis

Question 6

4 stages of natural conception: sperm production

Answer 6

good sperm, swimming well
hormonal control must be intact
outflow tract of sperm must be patent for sperm to be produced and released

Question 7

4 stages of natural conception: fertilisation

Answer 7

need sperm and egg to meet
fallopian tubes must be patent and functioning well
no ED or ejaculatory problems in male to adequate sperm is released into F reproductive tract

Question 8

4 stages of natural conception: implantation

Answer 8

uterus has to be normal

Question 9

what does natural conception rely on

Answer 9

functioning hormonal axis and gonads
ovarian reserve 
regular ovulation 
normal sperm production - motile
fertilisation - egg + sperm interaction and patent fallopian tube 
normal uterine cavity for implatation

Question 10

lifestyle factors that can effect fertility in males and females

Answer 10

age 
BMI (females) 
smoking 
alcohol 
rec drug use
stress?

Question 11

clinical definition (WHO) of infertility

Answer 11

inability to conceive over a 12mo period despite exposure to regular, unprotected intercourse
represents a prognosis based approach and provides practical guidance on when to initiate investigations

Question 12

epidemiological definition (WHO) of infertility

Answer 12

lack of conception after 2yrs in women of reproductive age (15-49) who are at risk of becoming pregnancy (sexually active, not using contraception)

Question 13

demographic definition (WHO) of infertility

Answer 13

inability to become pregnant with a live birth, within 5yrs of exposure, based upon a consistent union status, lack of contraceptive use, non-lactation and continuation of a desure for a kid

Question 14

when to refer

Answer 14

no conception after 1yr of unprotected intercourse

refer earlier if age>35yrs or known cause for infertility

Question 15

primary infertility

Answer 15

never managed to have a pregnancy before/man never fathered a child

Question 16

secondary infertility

Answer 16

couple have had a pregnancy before and now cannot get pregnant

Question 17

female infertility causes

Answer 17

ovulation problems - may not release egg regularly, egg reserve low
fallopian tube problem
uterine factors
endometriosis

Question 18

male infertility causes

Answer 18

hormone production that controls sperm release
issue with testicle
blockage sperm transport
ejaculation/erection problems

Question 19

approach to infertility investigations - think broadly about 4 factors

Answer 19

are eggs available?
are sperm available?
can they meet?
any other factors?

Question 20

infertility investigations: are eggs available

Answer 20

age

ovarian reserve test: FSH day 1-5 cycle, AMH

USS - antral-follicular count

Question 21

infertility investigations: is ovulation happening?

Answer 21

natural methods: basal body temp, cervical mucus

LH ovulation kits

ovulation calandre

D21 serum progesterone - day 21 of 28/30 cycle

Question 22

infertility investigations: are sperm available

Answer 22

semen analysis

Question 23

infertility investigations: can egg and sperm meet

Answer 23

intercourse - woman having no pain/discomfort and man doesn’t have erection/ejaculation problem

patent fallopian tube

Question 24

infertility investigations: how to check fallopian tube patency

Answer 24

hysterosaplingogram (HSG)

laparoscopic dye test

Question 25

infertility investigations: other tests

Answer 25

serum prolactin
thyroid function test
chlamydia screening
pelvic USS for uterine problems

also check: rubella immunity and if cervical smear is up to date

Question 26

management: ovulation disorders

Answer 26

optimise body weight, healthy lifestyle, exercise

medication - ovulation induction

• clomiphene citrate
• gonadotropins

laparoscopic ovarian drilling

Question 27

management: low sperm count or no sperm (azoospermia)

Answer 27

management depends on what causing low sperm e.g. hormones, testicles etc.

medical: gonadotropins

surgical sperm retreival

donor sperm - intrauterine inseminsation

intracytoplasmic sperm injection

Question 28

management: tubal problem

Answer 28

surgical approach: mild disease e.g. mild blockage or scar tissue

IVF

Question 29

unresolved fertility then what

Answer 29

IVF - in vitro fertilisation

Question 30

human fertilisation and embryology authority

Answer 30

regulatory authority 
licensing 
inspections 
forms: registration, treatment, outcome 
register

Question 31

IVF

Answer 31

fertilising egg with sperm outside the body in the lab

Question 32

IVF: own eggs

Answer 32

gonadotropin induced superovulation

gonadotropin injections, will produce multiple eggs in one cycle

Question 33

IVF: donor eggs

Answer 33

age
poor quality
ovarian failure
genetic cause

Question 34

IVF: partner’s sperm

Answer 34

fresh sample on day of egg collection

thawed frozen sample from surgical retrieval or fertility preservation

Question 35

IVF: donor sperm

Answer 35

single woman
same sex relationship 
azoospermia 
genetic cause
infection (HIV, hep b/c)

Question 36

IVF process: key steps

Answer 36

1. controlled ovarian stimulation
2. follicular monitoring
3. timing ovulation
4. egg collection
5. lab fertilisation
6. incubation/embryo development
7. embryo transfer
8. progesterone support

Question 37

IVF: post embryo transfer

Answer 37

progesterone pessaries
normal activity
pregnancy test after 2wks
if positive then scan at 7wks

Question 38

risks of IVF

Answer 38

ovarian hyper-stimulation syndrome
multiple pregnancy
medication side effects
procedure related - bleeding, infection

Question 39

IVF expanding indications

Answer 39

donor gametes
fertility preservation - gamete/embryo cyropreservation 
preimplantation genetic diagnosis 
assisted hatching 
in vitro maturation 
surrogacy