Infertility

Question 1

What percentage of couples will conceive within a year of regular unprotected sex?

<40 woman

Answer 1

85%

Question 2

When should you start investigations for infertility?

Answer 2

12 months of regular unprotected
Intercourse

6 months if woman >35

Question 3

Oocytes at puberty and menopause

Answer 3

400,000 at puberty

<1000 at menopause

Question 4

Causes of infertility

Answer 4

Sperm problems (30%)
Ovulation problems (25%)
Tubal problems (15%)
Uterine problems (10%)

Question 5

General lifestyle advice for couples trying to get pregnant

Answer 5

400mcg folic acid daily
Aim for healthy BMI
Avoid smoking and drinking excessive alcohol
Reduce stress as this may negatively affect libido
Intercourse every 2-3 days
Avoid timing intercourse

Question 6

Causes of anovulation

Answer 6

PCOS
Weight-related <18, >30
Ovarian failure
Hyperprolactinaemia

Question 7

Tubal disease causing infertility

Answer 7

PID
Pelvic surgery
Endometriosis

Question 8

Female history for infertility

Answer 8

Age
Duration, type of infertility
Menstrual cycle 
Tubal surgery/ PID
Menorrhagia, dysmenorrhea, pelvic pain
Pelvic surgery

Question 9

Examination of female factor infertility

Answer 9

BMI
Body hair distribution 
Galactorrhea
Secondary sexual characteristics 
Bimanual pelvic examination
Adhesion or masses

Question 10

When should LH, FSH be measured?

Answer 10

Day 2

Follicular phase

Question 11

When should progesterone be measured?

Answer 11

D12

Question 12

Investigations for female factor infertility

Answer 12

Follicular phase
Luteal phase
Rubella states
Tests of tubal patency: hysterosapingography 
Chlamydia

Question 13

Male history for infertility

Answer 13

General health
Alcohol/smoking
Previous surgery 
Previous infections
Sexual dysfunction

Question 14

Male factor infertility examination

Answer 14

Examination not essential 
Scrotum- varicocele
Testicular size
Testicular position: torsion
Prostate for chronic infection

Question 15

Semen analysis

Answer 15

• Semen analysis x2 (3 months)
  
  • Semen volume 1.5ml or more
  • PH 7.2 or more
  • Sperm concentration: 15million/ ml
  • Total number: >39/ ejaculate
  • Total motility: 40% or more motile, 32% or more with progressive motility
  • Vitality: 58% or more live spermatozoa
  • Sperm morphology: 4% or more
  • High scrotal temperature, drinking and smoking can affect so repeat after 3 months/ correcting factors

Question 16

Female hormone testing

Answer 16

LH/FSH D2-5
Progesterone D21
Anti-mullerian hormone
TFT
Prolactin

Question 17

High FSH

Answer 17

Poor ovarian reserve

Question 18

High LH

Answer 18

PCOS

Question 19

High progesterone day 21

Answer 19

Indicates ovulation has occurred

Corpus luteum formed

Question 20

Most accurate marker of ovarian reserve

Answer 20

Anti-Mullerian hormone
Most accurate marker of ovarian reserve
High level, good ovarian reserve

Question 21

Management of anovulation

Answer 21

Clomifene
Letrozole
Gonadotropin 
Ovarian drilling
Metformin 
Dopamine agonists for hyperprolactinaemia

Question 22

Management of tubal factors

Answer 22

Tubal cannulation during a hysterosalpingogram
Laparoscopy to remove adhesions or endometriosis
IVF

Question 23

Management of uterine factors

Answer 23

Surgery may be used to correct polyps, adhesions or structural abnormalities affecting fertility

Question 24

Management of sperm problems

Answer 24

Surgical sperm retrieval 
Blockage along vas deferens
Intra-cytoplasmic sperm injection
Donor insemination with sperm from a donor is another option for male factor infertility
IVF

Question 25

Male semen sample instructions

Answer 25

Abstain from ejaculation for 3-7 days Avoid hot baths, sauna and tights underwear Attempt to catch the full sample Deliver the sample to the lab within 1 hour of ejaculation Keep sample warm

Question 26

Lifestyle factors affecting quality and quantity of sperm

Answer 26

``` Hot baths Tight underwear Smoking Alcohol Raised BMI Caffeine ```

Question 27

Oligospermia

Answer 27

<15million

Question 28

Pre-testicular causes

Answer 28

Testosterone HPG axis Pituitary gland/ hypothalamus Stress, chronic conditions, hyperprolactinaemia Kallman syndrome

Question 29

Testicular causes

Answer 29

``` Mumps Undescended testes Trauma Radiotherapy Chemotherapy Cancer ```

Question 30

Genetic or congenital disorders that result in defective or absent sperm produciton

Answer 30

Klinefelter’s syndrome Y chromosome deletions Sertoli cell-only syndrome Anorchia

Question 31

Post-testicular causes

Answer 31

``` Damage to testicular or vas deferens from trauma, surgery or cancer Ejaculatory duct obstruction Retrograde ejaculation Scarring from epididymitis Absence of vas deferens Young’s syndrome ```

Question 32

Investigations for male factor infertility

Answer 32

``` Hormonal analysis Genetic testing Transrectal ultrasound or MRI Vasography Testicular biopsy ```

Question 33

Management of male factor infertility

Answer 33

Surgical sperm retrieval where is obstruction Surgical correction of an obstruction in vas deferens Intra-uterine insemination Intracytoplasmic sperm injection Donor insemination

Question 34

IVF attempt success

Answer 34

25-30%

Question 35

IVF complications

Answer 35

Failure Multiple pregnancy Ectopic pregnancy Ovarian hyper stimulation syndrome

Question 36

Risk factors for ovarian hyper stimulation syndrome

Answer 36

``` Younger age Lower BMI Raised anti-Mullerian hormone Higher antral follicle count PCOS Raised oestrogen levels during ovarian stimulation ```

Question 37

Management of ovarian hyper stimulation syndrome

Answer 37

``` Oral fluids Monitor urine output LMWH Ascitic fluid removal IV colloids ```