Infertility

Question 1

Criteria for infertility referral

Answer 1

• No conception after one year of regular unprotected sex
• Age >35 years
• Known cause of infertility

Question 2

Definition of infertility

Answer 2

• Clinical → Inability to conceive in 12 month period despite regular unprotected intercourse

Question 3

Lifestyle factors affecting fertility

Answer 3

• Age
• BMI
• Smoking
• Alcohol
• Recreational drugs
• Stress

Question 4

Human fertility

Answer 4

• Inefficient compared to other mammals
• Conception per cycle of 20% at peak
• Declines with age

Question 5

Why does age matter in fertility

Answer 5

• With age there is a reduction in ovarian reserve
• Predetermined egg reserve at birth
• Also a reduced egg quality with age

Question 6

Factors affecting normal conception

Answer 6

• Functional hormonal axis and goads
• Ovarian reserve
• Regular ovulation
• Normal sperm production
• Fertilisation → egg and sperm interaction in a patent Fallopian tube
• Normal uterine cavity → implantation

Question 7

Key processes for normal conception

Answer 7

• Ovulation (F)
• Sperm production (M)
• Fertilisation (F)
• Implantation (F)

Question 8

Female infertility examination

Answer 8

• Weight
• Height
• BMI
• Fat and hair distribution
• Galactorrhoea
• Abdominal and pelvic examination

Question 9

Hirsutism

Answer 9

• Abnormal growth of excess body hair due to excess male sex hormone (Androgens)

Question 10

What to look out for in pelvic examination

Answer 10

• Masses
• Pelvic distortion
• Tenderness
• Vaginal septum
• Cervical abnormalities

Question 11

Initial investigations for infertility

Answer 11

• Body mass index (low could indicate anovulation, high could indicate PCOS)
• Semen analysis
• Rubella immunity
• Chlyamdia

Question 12

Further investigations

Answer 12

• Serum LH and FSH (days 2-5)
• Serum progesterone (7 days before end of cycle)
• Anti-Mullerian hormone
• Thyroid function test
• Prolactin
• Pelvic ultrasound
• Hysterosalpingogram
• Laparascopy and dye test

Question 13

HyCosy scan

Answer 13

• Scan to tests for damage and blockage of the fallopian
• Substitute for HSG or laparoscopy and dye

Question 14

Hysterosalpingogram

Answer 14

• Screen for shape uterus and patency of Fallopian tubes
• Injection of contrast medium into cervix filling uterine cavity and Fallopian tube
• X-ray image taken

Question 15

Laparoscopy and dye test

Answer 15

• Dye injected into uterus and should enter Fallopian tubes and spill out the ends of the tubes laparoscopically
• This will not be seen during obstruction
• Assessment for endometriosis and pelvic adhesions

Question 16

Important features of male infertility history

Answer 16

• Developmental history
  
  • Testicular descent
  • Changes in shaving frequency
  • Loss go body hair
• PMH
  
  • Infections → mumps, STIs
  • Varicocele repair
  • Vasectomy
  • Previous fertility
• Drugs
  
  • Anabolic steroids
  • Chemotherapy
  • Recreation drugs
• Social history
  
  • Radiation exposure
  • Alcohol
  • Smoking

Question 17

Important features of male infertility examination

Answer 17

• Weight
• Height
• BMI
• Fat and hair distribution (hypoandrogenism
  
  • Increased body fat
  • Decreased muscle mass
  • Loss of axillary, pubic and facial hair
• Genital examination
  
  • Epididymis
  • Testes
  • Vas deferens
  • Varicocele

Question 18

Epididymitis

Answer 18

• Inflammation of epidermis
• Causes seminiferous tubule necrosis
• Disrupts spermatogenesis
• Cause
  
  • STDs
  • Chlamydia
  • Gonorrhea
  • TB and mumps

Question 19

Varicocele

Answer 19

• Dilatation of pampiniform plexus of spermativ veins in scrotum
• Causes low sperm concentration → infertility
  *

Question 20

Kinlefelter syndrome

Answer 20

• Genetic conditions with an extra copy of X chromosome
• Commonest cause of primary hypogonadism → impaired spermatogenesis and testosterone deficiency

Question 21

Absent vas deferens

Answer 21

• Normal function development of testes
• Sperm cannot travel through vas deferens to be ejaculated
• Can be a sign of cystic fibrosis

Question 22

Classification of ovulatory disorder

Answer 22

• Group 1 → hypothalamic pituitary failure
• Group 2 → hypothalamic-pituitary-ovarian dysfunction
• Group 3 → ovarian failure

Question 23

Management of anovulation

Answer 23

• Weight loss → overweight patients with PCOS
• Ovulation induction
  
  • Clomifene
  • Letrozole
  • Gonadotropins
• Ovarian drilling → for PCOS
• Metformin → in insulin insensitivity in conjunction with obesity (PCOS)

Question 24

Clomifene

Answer 24

• Selectie oestrogen receptor modulator
• Stops negative feedback of estrogen to hypothalamus
• Causes greater release of FSH and LH

Question 25

Gonadotropin

Answer 25

• Induction of multiple follicles
• Alternative to Clomifene
• Risk of multiple pregnancies and ovarian hyper stimulation syndrome

Question 26

Management of tubal factors

Answer 26

• Tubal cannulation during hysterosalpingogram
• Laparascopic removal of adhesions or endometriosis
• In vitro fertilisation
  *

Question 27

Management of infertile males

Answer 27

• In vitro fertilisation and intracytoplasmic sperm injection
• Intra-uterine inseminsation
• Surgery
  
  • Reversal of vasectomy
  • Surgical sperm retrieval
  • Surgical correction → vas deferens
• Donor insemination

Question 28

Unexplained infertility

Answer 28

• Contraindications → oral ovarian stimulation agents (Clomifene)
• Over IVF