Infertility

Question 1

What are the key factors that must work effectively in order for conception to occur?

Answer 1

• Ovulation
• Sperm production
• Fertilisation
• Implantation

Question 2

Definition of infertility?

Answer 2

Unable to conceive after 12 months exposure to regular unprotected sex

Question 3

When do you refer someone for infertility?

Answer 3

• No conception after 1 year of regular unprotected intercourse

Early referral if:

• Age >35yrs
• Known cause for infertility

Question 4

How is infertility investigated?

Answer 4

• Are eggs available?
• Are sperm available?
• Can they meet?
• Any other factor?

Question 5

How do you investigate whether eggs are available?

Answer 5

• Maternal age
• Ovarian reserve test (blood test and scan)
• Blood test (FSH, D1-D5 of cycle, AMH)
• US (antral follicular count)

Question 6

How do you investigate if ovulation is occurring?

Answer 6

Used by couples:

• BBT, Cervical mucus
• LH ovulation kits
• Ovulation calendar

Used to investigate:
- D21 serum progesterone

Question 7

What level of progesterone is satisfactory for ovulation?

Answer 7

20nmol/l

Question 8

How do you test for sperm availability?

Answer 8

Semen analyisis

Question 9

How do you check fallopian tube patency?

Answer 9

• If no pelvic infection or gynaecological problem in the past > hysterosalpingogram (HSG)
• If any of above > laparoscopic dye test

Question 10

Other tests to be done for infertility?

Answer 10

• Serum prolactin
• TFT
• Chlamydia screening
• Pelvic US for uterine problems
• Rubella immunity
• Cervical smear upto date

Question 11

Conservative management for ovulation disorders?

Answer 11

• Optimise body weight, healthy lifestyle, exercise

Question 12

Medical management for ovulation disorders?

Answer 12

Ovulation induction

• Clomiphene citrate
• Gonadotrophin

Question 13

Surgical management for ovulation disorders?

Answer 13

Laparoscopic ovarian drilling

Question 14

What is the management for problems with sperm?

Answer 14

• Gonadotrophins
• Surgical sperm retrieval
• Donor sperm
• ICSI (intracytoplasmic sperm injection)

Question 15

What is the management for tubal problems?

Answer 15

• Role of surgery limited to mild tubal disease

- IVF

Question 16

Treatment for endometriosis?

Answer 16

• Ablation or resection of spots
• Adhesiolysis
• Cystectomy for endometrioma

Question 17

Other treatments for infertility?

Answer 17

Uterine surgery for removal of polyps/fibroids

Adhesiolysis for synechiae

Question 18

How is unresolved infertility managed?

Answer 18

IVF

Question 19

Sperm and egg retreival in IVF?

Answer 19

1. Given gonadotrophin injections to produce multiple eggs in one cycle (donor eggs also can be used)
2. Sperm sample collected on day of egg recovery (fresh from partner/frozen samples/donor sperm)

Question 20

Key steps in IVF?

Answer 20

• Controlled ovarian stimulation
• Follicular monitoring
• Timing ovulation
• Egg collection
• Lab fertilisation (insemination/ICSI)
• Incubation/embryo development
• Embryo transfer
• Progesterone support

Question 21

What happens once the embryos have been transferred to the female?

Answer 21

• Progesterone pessaries
• Normal activity
• Pregnancy test at 2 weeks
• If positive scan at 7 weeks

Question 22

What are the risks of IVF?

Answer 22

• Ovarian hyperstimulation syndrome
• Multiple pregnancy
• Medication side effects
• Procedure related risks

Question 23

What are the long term effects?

Answer 23

• Children born (no difference noted only got short term data)
• Risk of ovarian cancer not confirmed
• Absolute risk to women and children low