Infertility

Question 1

Definition of infertility

Answer 1

Unable to become pregnancy within 1 year of regular unprotected intercourse

Question 2

Statistically a couple stands an 80% chance of conceiving within 1 year if:

Answer 2

The woman is <40yo
They do not use contraception
They have regular intercourse
The overall probability increases to 90% if considered over 2 years.

Question 3

Causes of female infertility

Answer 3

Low Ovarian reserve
Ovulation problems
Structural problems of uterus
Tubal problems
Unexplained
hypothalamic pituitary ovarian dysfunction (predominantly pcos)
Hypothalamic pituitary failure (hypogonadotrophic hypogonadism)
Endocrine disorders
Premature Ovarian Failure

Question 4

Premature Ovarian Failure

Answer 4

loss of function of the ovaries before the age 40.

Question 5

Causes of Premature Ovarian Failure

Answer 5

Usually idiopathic
Genetic include Turners syndrome and Fragile X Syndrome
Smoking
Radiation/chemotherapy
Autoimmune disease
High FSH/LH, low oestrogen

Question 6

General Advice for couples trying to get pregnant

Answer 6

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
Timed intercourse to coincide with ovulation is not necessary or recommended

Question 7

Female infertility Investigations

Answer 7

BMI
Chlamydia screening
Semen analysis
Female hormonal testing - AMH,LH FSH, TFTs, prolactin
Rubella immunity in the mother
US
Hysterosalpingogram
laparoscopy and dye

Question 8

Mx of an Anovulation

Answer 8

BMI related ( decrease if PCOS, increase if low BMI)
moderating their exercise levels if they undertake high levels of exercise.
Clomifene may be used to stimulate ovulation
Letrozole may be used instead of clomifene to stimulate ovulation (aromatase inhibitor with anti-oestrogen effects)
Gonadotropins may be used to stimulate ovulation in women resistant to clomifene

Question 9

Clomifene MOA

Answer 9

anti-oestrogen (a selective oestrogen receptor modulator). It is given on days 2 to 6 of the menstrual cycle. It stops the negative feedback of oestrogen on the hypothalamus, resulting in a greater release of GnRH and subsequently FSH and LH.

Question 10

Superovulation/controlled ovarian hyperstimulation

Answer 10

process of inducing a woman to release more than one egg in a month
used for PCOS or PCOS with failed clomiphene
tx is started between days 3 - 5 of the cycle, by daily injection with FSH
monitored by US and blood tests to reduce risk of overstimulation/multiple pregnancy
When the biggest follicle reaches 17mm in diameter, with no more than 2 others of this size, an injection of Human Chorionic Gonadotrophin - HCG is given to induce ovulation with planned intercourse

Question 11

Mx PCOS for fertility

Answer 11

If BMI over 30, to lose weight
Ovarian drilling
Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)

Question 12

Advice for Unexplained infertility:

Answer 12

clomifene citrate as a standalone treatment does not increase the chances of a pregnancy or a live birth
Advise them to try sexual intercourse for a total of 2 years (this can include up to 1 year before their fertility investigations) before IVF will be considered.

Question 13

Factors Affecting Semen Analysis

Answer 13

Hot baths
Tight underwear
Smoking
Alcohol
Raised BMI
Caffeine

Question 14

Causes of male infertility

Answer 14

hypothalamus/pituitary malfunction (low LH and FSH resulting in low testosterone)
tumours
debilitating illness(hemochromatosis, sarcoidosis, tuberculosis),
syndromes:Kallmann’s, Prader-Willi
latent infection possibly prostatis or urethritis
Testicular damage from:Mumps, orchitis , cancer,Undescended testes, Trauma
Post-Testicular Causes: Ejaculatory duct obstruction, Retrograde ejaculation, Scarring from chlamydia,Absence of the vas deferens eg CF

Question 15

Male infertility Ix

Answer 15

Hormonal analysis with LH, FSH and testosterone levels
Genetic testing
Further imaging, such as transrectal ultrasound or MRI
Vasography, which involves injecting contrast into the vas deferens and performing xray to assess for obstruction
Testicular biopsy

Question 16

Mx sperm problems

Answer 16

pulsatile replacement of gonadotropin releasing hormone(GnRH) or injections of gonadotropins(FSH/LH) usually hCG or hMG
correction of an obstruction in the vas deferens

Question 17

Assisted conception treatment strategies:

Answer 17

IVF: own or donor sperm

Surgical sperm retrieval
is used when there is a blockage somewhere along the vas deferens preventing sperm from reaching the ejaculated semen

Intra-uterine insemination
involves collecting and separating out high-quality sperm, then injecting them directly into the uterus

Intracytoplasmic sperm injection (ICSI)
involves injecting sperm directly into the cytoplasm of an egg, useful when there are significant motility issues, a very low sperm count

Donor insemination with sperm from a donor

Question 18

IVF

Answer 18

In vitro fertilisation involves fertilising an egg with sperm in a lab, then injecting the resulting embryo into the uterus
Each attempt has a roughly 25 – 30% success rate at producing a live birth.

Question 19

Steps of IVF

Answer 19

Suppressing the natural menstrual cycle (GnRH)
Ovarian stimulation (FSH)
Oocyte collection (hCG works like LH)
Progesterone is used from the time of oocyte collection until 8 – 10 weeks gestation, usually in the form of vaginal suppositories to mimic corpus luteum role
Insemination / intracytoplasmic sperm injection (ICSI)
Embryo culture
Embryo transfer

A pregnancy test is performed around day 16 after egg collection. When this is positive, implantation has occurred.

Question 20

Ovarian hyperstimulation syndrome

Answer 20

provoked by the “trigger injection” of hCG 36 hours before oocyte collection.
syndrome presents within 7 days of the hCG injection
increase in vascular endothelial growth factors results in oedema, ascites and hypovolaemia.

Question 21

Clinical presentation Ovarian hyperstimulation syndrome

Answer 21

Abdominal pain and bloating
N,V,D
Hypotension
Hypovolaemia
Ascites
Pleural effusions
Renal failure
Prothrombotic state
renin level correlates with the severity of the condition

Question 22

Mx Ovarian hyperstimulation syndrome

Answer 22

Oral fluids
Monitoring of urine output
Low molecular weight heparin (to prevent thromboembolism)
Ascitic fluid removal (paracentesis) if required
IV colloids (e.g. human albumin solution)