Infertility

Question 1

What history would you obtain from a male partner?

Answer 1

Previous pregnancies fathered

Medical history
- Mumps
- Testicular trauma
- Chemotherapy agents/radiotherapy
- CF - absent vas deferens
Surgical history
- e.g. previous suspended testes needing orchidopexy
Smoking
Alcohol
Drugs
Medications
Occupation - e.g. truck driver (heat to testicles) etc

Erectile dysfunction/ejaculatory dysfunction (failure to achieve or retrograde)

Question 2

What examination would you perform on the male partner?

Answer 2

• height, weight, BMI
• virilisation or lack thereof
• stigmata of Klinefelter syndrome e.g. tall stature, gynaecomastia, relative under-virilisation, small soft testes
• testicular exam (size, consistency), presence of vas

Question 3

Outline differentials for female factor infertility

Answer 3

Hypogonadotrophic hypogonadism:

• Functional
• Kallmann’s syndrome
• Pituitary damage: infection, Sheehan’s syndrome, surgery or irradiation
• Hyperprolactinaemia
• Thyroid dysfunction

Ovulation dysfunction (normogonadtrophic normooestrogenic anovulation: PCOS

Hypergonadotrophic hypogonadism:

• POI
• Turner’s syndrome
• Fragile X

Tubal:

• Infection
• Previous surgery
• Endometriosis

Uterine:

• Adhesions
• Submucous fibroid
• Congenital uterine anomalies

Question 4

Outline your investigations and work up of female factor infertility

Answer 4

First-line investigations for all women:

• Semen analysis (haha)
• Day 2 FSH, LH and oestradiol.
• Mid-luteal progesterone
• PRL, TSH
• PCOS: free testosterome, FAI, SHBG
• AMH for ovarian reserve
• Booking bloods, smear, swabs, STI screening

Tubal:

• HSG
• HyCoSy
• Saline sonohysterography
• Laparoscopic dye test

Uterine:

• Pelvic USS
• HyCoSy
• HSG
• Saline sonohysterograophy
• Hysteroscopy

Question 5

Outline what is Kallmann’s syndrome and fertility treatment options

Answer 5

• Kallmann’s syndrome is a genetic condition where the body is unable to produce GnRH from the hypothalamus. This leads to low levels of FSH and LH which in turn lead to a lack of oestradiol and ovarian function.
• Women with this condition may not go through puberty naturally or have puberty arrest partway through and leads to infertility.
• Fertility treatment options:
  
  • Pulsatile GnRH or gonadotrophins for ovulation induction.

Question 6

Outline approach to woman with infertility and endometriosis

Answer 6

• Primary laparoscopic surgery and treatment of symptomatic endometriosis improves birth rate:
  
  • Repeat surgery associated with lower pregnancy rates.
• Endometrioma present:
  
  • IVF unless endometrioma is limiting oocyte retrieval with IVF.
  • Surgery to remove them associated with reduced ovarian reserve.
• Mild-mod endometriosis:
  
  • Natural conception
  • Ovulation induction + IUI
  • IVF +/- ICSI
• Moderate-severe endometriosis:
  
  • IVF +/- ICSI