Infertility

Question 1

What percentage of couples will conceive naturally after 1 yr of regular unprotected sex?

Answer 1

85%

Question 2

What proportion of couples will struggle to conceive naturally

Answer 2

1 in 7

Question 3

How long must couples try to conceive for without success before investigation and referral for infertility should be initiated?

Answer 3

> 12 months
or
6 months if the woman is >35yo due to reducing ovarian stores

Question 4

List the causes of infertility

Answer 4

Sperm problems (30%)
Ovarian problems (25%)
Tubal problems (15%)
Uterine problems (10%) 
Unexplained (20%)

Question 5

What percentage of infertile couples have a mix of male and female causes?

Answer 5

40%

Question 6

Give some general advice for couples trying to get pregnant

Answer 6

Woman should take 400mcg folic acid daily

Aim for healthy BMI

Avoid smoking and drinking excess alcohol

Reduce stress as this may negatively impact libido and relationship

Aim for intercourse every 2-3 days

Avoid timing intercourse

Question 7

What investigations can be ordered for infertility in primary care?

Answer 7

BMI
Chlamydia screen
Semen analysis
Female hormonal testing 
Rubella immunity in the mother

Question 8

List the female hormones tested when investigating infertility

Answer 8

Serum LH and FSH (on days 2-5)
Serum progesterone on day 21 (or 7 days before the end)
Anti-Mullerian hormone
Thyroid function tests
Prolactin if symptoms of galactorrhoea or amenorrhoea

Question 9

What does a high FSH indicate

Answer 9

Poor ovarian reserve - pituitary producing extra FSH in attempt to stimulate development

Question 10

What does a rise in day 21 progesterone indicate?

Answer 10

Ovulation has occured - corpus luteum formed and secreting progesterone

Question 11

When can anti-Mullerian hormone be measured?

Answer 11

Any time of cycle

Question 12

What is anti-Mullerian hormone a marker of?

Answer 12

Ovarian reserve

Question 13

What releases anti-Mullerian hormone?

Answer 13

Granulosa cells in the follicles

Question 14

When does anti-Mullerian hormone decrease?

Answer 14

As the eggs are depleted

Question 15

What investigations for fertility can be performed in secondary care?

Answer 15

Ultrasound pelvis - PCOS or any structural abnormality

Hysterosalpingogram - patency of fallopian tubes

Laparoscopy and dye test - patency of the tubes, adhesions and endometriosis

Question 16

What is a hysterosalpingogram?

Answer 16

Scan used to assess the shape of the uterus and the patency of the fallopian tubes

Question 17

What are the benefits of a hysterosalpingogram?

Answer 17

Diagnostic

Therapeutic - seems to increase rate of conception without any other intervention

Question 18

Describe how a hysterosalpingogram is done

Answer 18

Small tube into cervix
Contrast medium injected through the tube and fills the uterine cavity and fallopian tubes
X-ray images are taken and the contrast shows up on the X-ray giving an outline of the uterus and tubes
If dye does not fill a tube then will suggest tubal obstruction

Question 19

What are the risks of hysterosalpingogram?

Answer 19

Infection risk

Question 20

Describe the laparoscopy and dye test

Answer 20

Patient admitted for laparoscopy
During procedure, dye is injected into the uterus and should be seen entering the fallopian tubes and spilling out of the end of the tubes
This will not be seen in tubal obstruction
During laparoscopy, the surgeon can also assess for endometriosis or pelvic adhesions and treat these

Question 21

Describe the management of anovulation

Answer 21

Weight loss  
Clomifene
Letrozole
Gonadotrophins 
Ovarian drilling
Metformin

Question 22

What is clomifene

Answer 22

Anti-oestrogen (selective oestrogen receptor modulator)
Given on days 2 to 6 of the menstrual cycle
Stops the negative feedback of oestrogen on the hypothalamus resulting in greater GnRH release and subsequently FSH and LH

Question 23

Describe ovarian drilling

Answer 23

Laparoscopic surgery
Surgeon punctures holes in the ovaries using diathermy or laser therapy
Can help improve hormone profile and result in regular ovulation and fertility

Question 24

List some management options of tubal factors

Answer 24

Tubal cannulation during hysterosalpingogram

Laparoscopy to remove adhesions or endometriosis

IVF

Question 25

List some management options of uterine factors

Answer 25

Surgery to correct polyps, adhesions or structural abnormalities

Question 26

List the management of sperm problems

Answer 26

Surgical sperm retrieval
Surgical correction 
Intra-uterine insemination
Intracytoplasmic sperm injection  
Donor insemination

Question 27

Describe surgical sperm retrieval

Answer 27

Used when there is a blockage somewhere along the vas deferens preventing sperm reaching the ejaculated semen
A needle and syringe is used to collect sperm directly from the epididymis through the scrotum