Infertility

Question 1

When should a referral for infertility be initiated

Answer 1

After the couple has been trying to conceive without success for 12 months.

Can be reduced to 6 months if the woman is older than 35

Question 2

Causes of infertility

Answer 2

Sperm problems 
Ovulation problems 
Tubal problems 
Uterine problems 
Unexplained

Question 3

General advice for infertility

Answer 3

The woman should be taking 400mcg folic acid daily

Aim for a healthy BMI

Avoid smoking and drinking excessive alcohol

Reduce stress as this may negatively affect libido and the relationship

Aim for intercourse every 2 – 3 days

Avoid timing intercourse

Question 4

Timed intercourse

Answer 4

Timing intercourse to coincide with ovulation is not necessary or recommended as it can lead to increased stress and pressure in the relationship

Question 5

Investigations for infertility

Answer 5

BMI

• low could indicate anovulation
• high could indicate PCOS)

Chlamydia screening

Semen analysis

Female hormonal testing

Rubella immunity in the mother

Question 6

Female hormone testing involves

Answer 6

Serum LH and FSH on day 2 to 5 of the cycle

Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle).

Anti-Mullerian hormone

Thyroid function tests if suggestive

Prolactin

Question 7

High FSH

Answer 7

Suggests poor ovarian reserve (the number of follicles that the woman has left in her ovaries)

Question 8

High LH

Answer 8

Can indicated PCOS

Question 9

Anti-Mullerian hormone

Answer 9

Can be measured at any time during the cycle and is the most accurate marker of ovarian reserve

Question 10

Investigations for infertility performed in secondary care

Answer 10

Ultrasound pelvis - polycystic ovaries or any structural abnormalities in the uterus

Hysterosalpingogram - patency of the fallopian tubes

Laparoscopy and dye test - patency of the fallopian tubes, adhesions and endometriosis

Question 11

Tubal cannulation

Answer 11

Under xray guidance

Performed during the hysterosalpingogram to open up the tubes

Question 12

Risks of a hysterosalpingogram and how it’s minimised

Answer 12

Risk of infection - prophylactic antibiotics

Screening for chlamydia and gonorrhoea should be done before the procedure

Question 13

Management of anovulation

Answer 13

Weight loss for overweight patients

Clomifene - stimulate ovulation

Letrozole instead of clomifene to stimulate ovulation

Gonadotropins - used to stimulate ovulation in women resistant to clomifene

Ovarian drilling - used in polycystic ovarian syndrome

Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)

Question 14

Letrozole mechanism of action

Answer 14

Aromatase inhibitor with anti-oestrogen effects

Question 15

Clomifene

Answer 15

Selective oestrogen receptor modulator (SERM)

Given on days 2 to 6 of the menstrual cycle

Stops the negative feedback of oestrogen on the hypothalamus, resulting in a greater release of GnRH and subsequently FSH and LH

Question 16

Ovarian drilling

Answer 16

Laparoscopic surgery

Surgeon punctures multiple holes in the ovaries using diathermy or laser therapy.

Improve the hormonal profile and result in regular ovulation and fertility

Question 17

Management of Tubal Factors

Answer 17

Tubal cannulation during a hysterosalpingogram

Laparoscopy to remove adhesions or endometriosis

In vitro fertilisation (IVF)

Question 18

Management of Uterine Factors

Answer 18

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

Question 19

Management of Sperm Problems

Answer 19

Surgical sperm retrieval

Surgical correction

Intrauterine insemination

Intracytoplasmic sperm injection (ICSI)

Donor insemination

Question 20

Donor insemination

Answer 20

Sperm from a donor used to inseminate woman

Question 21

Surgical sperm retrieval

Answer 21

When there is a blockage somewhere along the vas deferens preventing sperm from reaching the ejaculated semen

A needle and syringe is used to collect sperm directly from the epididymis through the scrotum

Question 22

Surgical correction of sperm problems

Answer 22

Surgically correct vas deferens occlusion

Question 23

Intra-uterine insemination

Answer 23

Collecting and separating out high-quality sperm

Injecting them directly into the uterus

Question 24

Intracytoplasmic sperm injection

Answer 24

Involves injecting sperm directly into the cytoplasm of an egg

These fertilised eggs become embryos, and are injected into the uterus of the woman.

Question 25

When is intracytoplasmic sperm injection useful

Answer 25

Useful when there are significant motility issues, a very low sperm count and other issues with the sperm