Infertility

Question 1

What is infertility?

Answer 1

Failure to conceive after minimum of 1y of regular unprotected intercourse.

· Primary: no previous pregnancy

· Secondary: previously fertile

Question 2

What is the aetiology of infertility?

Answer 2

Idiopathic 15%.

Female 50%: Tubal disease, anovulation (PCOS, RT obstruction, enfomatriosis, uterine anomalies/fibroids/ashermans)

Male 35%: chromosomal, endocrine, drugs, irradiation, infection (STI, mumps), RT obstruction, hypogonadotrophic hypogonadism, trauma (torsion), varicocele, ejaculaiton disorders, AI causes (antisperm antibodies), previous maldescended testes.

RF smoking, alcohol, marjuana, excess exercise, extreme BW, female age >35.

Question 3

What is the epidemiology of infertility?

Answer 3

10-15% couples of reproductive age

Question 4

What would you find in the history and exam of infertility?

Answer 4

Duration, type of infertility, coital frequency, menstrual hx, PCOS symptoms, contraceptive Hx, STI hx, surgery/gynae hx, PMHx, Social Hx.

General: BMI, PCOS signs, Thyroid dysfunciton signs, II sex characteristics.

Speculum/vaginal: uterine size, mobility, evidence of infection.

Question 5

What investigations do you do for infertility?

Answer 5

Screen for HIV/HepBC if progress to assisted reproduction tachniques.

MalesL semen analysis (pH, sperm count, volume, motility, WCC). If abnormal, FSH/LH levels, karyotype, USS testes.

Females:

· Bloods: Day21 progestrone (ovulation), Day2/3 LH/FSH (ovarian reserves), serum TFT, testosterone, androstedione, SHBG, prolactin, rubella immunity.

· Microbiology: screen for STI/chlamydia.

· Imaging: USS pelvis for uterine anomalies, cysts, polyps, HSG (tubal patency). Laparoscopy and dye test. ?Hysteroscopy.

Question 6

What is the management of infertility?

Answer 6

Manage identified social and environmental factors. Ovulaiton induction with clomiphene citrate or gonadotrophin, IUI, IVF. Male: requires urological input. Try and retrieve sperm for IVF, if not, consider donor.

Female:
· Anovulatory: correct endocrinopathies, ovulaiton induction, IVF. With PCOS, consider metformin, ovulaiton induction, laproscopic ovarian drilling. Counselfor egg donation if high FSH.

· Uterine factors: hysteroscopic management.

· Tubal factors: consider laparoscopic procedures, often requires IVF.

· Endometriosis: surgical management, may require IVF.

Question 7

What is the Complications/Prognosis of infertility?

Answer 7

Psychological distress, complication of fertility intervention (i.e. OHSS, multiple pregnancy, ectopic) PGX depends on underlying aetiology.