Infertility

Question 1

What proportion of couples fail to conceive naturally?

Answer 1

1/7

Question 2

After trying to conceive for how long should investigations and referrals for infertility be started? (2 options)

Answer 2

1. 12 months
2. 6 months if: woman 35+ yrs

Question 3

What are the causes of infertility? (5 things)

Answer 3

1. Sperm (30%)
2. Ovulation (20%)
3. Tubal (15%)
4. Uterine (10%)
5. Unexplained (20%)

Question 4

What is some general advice for infertility? (5 things)

Answer 4

1. Woman takes 400mcg folic acid daily
2. Have healthy BMI
3. X Smoking / Alcohol
4. Reduce stress (fx libido + relationship)
5. Intercourse every 2-3 days

Question 5

What initial investigations should you do in primary care for infertility? (5 things)

Answer 5

1. BMI
2. Chlamydia screening
3. Semen analysis
4. Female hormone testing
5. Rubella immunity in mother

Question 6

What does a LOW BMI suggest the cause of infertility is?

Answer 6

Anovulation

Question 7

What does a HIGH BMI suggest the cause of infertility is?

Answer 7

PCOS

Question 8

What does Female hormone testing involve? (5 things)

Answer 8

1. Serum LH + FSH
2. Serum progesterone
3. Anti-Mullerian hormone
4. TFTs (if symptoms suggest dis)
5. Prolactin (when symptoms of galactorrhoea / amenorrhoea)

Question 9

Why should you check Prolactin in infertility?

Answer 9

Hyperprolactinaemia causes anovulation

Question 10

Which day range is Serum LH + FSH checked?

Answer 10

Day 2-5

Question 11

Which day is Serum progesterone checked?

Answer 11

Day 21

(or 7 days b4 end of cycle if not 28 day cycle)

Question 12

What does High FSH suggest?

Answer 12

Poor ovarian reserve (aka number of follicles left in ovaries)

Question 13

What explains the High FSH in poor ovarian reserve?

Answer 13

Pit gland prod extra FSH in attempt to stimulate follicular dev

Question 14

What does Low LH suggest?

Answer 14

PCOS

Question 15

What does a rise in Progesterone @ day 21 indicate? (2 things)

Answer 15

1. Ovulation has occurred
2. Corpus luteum formed + started secreting progesterone

Question 16

When in the cycle can Anti-Mullerian hormone be tested for?

Answer 16

Anytime

Question 17

What is Anti-Mullerian hormone a marker for?

Answer 17

Most accurate marker of ovarian reserve

Question 18

What is Anti-Mullerian hormone released by?

Answer 18

Granulosa cells in follicles

Question 19

What does Low Anti-Mullerian hormone suggest?

Answer 19

Eggs are depleted

Question 20

What further investigations should you for infertility in Secondary care? (3 things)

Answer 20

1. US Pelvis
2. Hysterosalpingogram
3. Laparoscopy + Dye test

Question 21

What are you looking for in a US Pelvis of infertility? (2 things)

Answer 21

1. PCOS
2. Structural abn in uterus

Question 22

What are you looking for in a Hysterosalpingogram of infertility?

Answer 22

Fallopian tube patency

Question 23

What are you looking for in a Laparoscopy + Dye test of infertility? (3 things)

Answer 23

1. Fallopian tube patency
2. Adhesions
3. Endometriosis

Question 24

What is a benefit of a Hysterosalpingogram?

Answer 24

Can do Tubal cannulation during it –> opens up tube –> restores fertility

Question 25

What is a risk of having a Hysterosalpingogram?

Answer 25

Infection

Question 26

What precautions are taken with Hysterosalpingogram to reduce risk of infection? (2 things)

Answer 26

1. Prophylactic abx 2. Chlamydia + Gonorrhoea screening b4 hand

Question 27

What is a benefit of a Laparoscopy?

Answer 27

Can treat adhesions / endometriosis on the job

Question 28

What are the management options for infertility caused by ANOVULATION? (6 things)

Answer 28

1. Weight loss (if overweight +/- PCOS) 2. Clomifene 3. Letrozole (instead of clomifene) 4. Gonadotropins (if resistant to clomifene) 5. Ovarian drilling (if PCOS) 6. Metformin (for insulin sensitivity / obesity related to PCOS)

Question 29

What drug class in Clomifene?

Answer 29

Anti-oestrogen (selective oestrogen receptor modulator)

Question 30

What day range is Clomifene given?

Answer 30

Days 2-6 of menstrual cycle

Question 31

What are the physiological steps of Clomifene in restoring fertility? (4 steps)

Answer 31

1. Stops negative feedback of oestrogen on hypothalamus 2. Increased GnRH release 3. Increased FSH + LH 4. Ovulation

Question 32

What are the physiological steps of Ovarian drilling in restoring fertility? (3 steps)

Answer 32

1. Multiple holes drilled in ovaries using diathermy / laser (@ laparoscopy) 2. Womans hormone profile improved 3. Regular ovulation

Question 33

What are the management options for infertility caused by TUBAL DEFECTS? (3 things)

Answer 33

1. Tubal cannulation @ hysterosalpingogram 2. Laparoscopy to remove adhesions / endometriosis 3. IVF

Question 34

What is the management option for infertility caused by Uterine DEFECTS?

Answer 34

Surgery to correct polyps / adhesions / structural abn

Question 35

What are the management options for infertility caused by Sperm defects? (5 things)

Answer 35

1. Surgical sperm retrieval 2. Surgical correction of vas deferens obst 3. Intra-uterine insemination 4. Intracytoplasmic sperm infection (ICSI) 5. Donor insemination

Question 36

What does Intra-uterine insemination involve? (2 steps)

Answer 36

1. Collecting + separating high quality sperm 2. Injecting them directly into uterus

Question 37

What does Intracytoplasmic sperm injection (ICSI) involve? (2 steps)

Answer 37

1. Injecting sperm directly into cytoplasm of egg (which then becomes embyro) 2. Embryo injected into uterus

Question 38

When is Intracytoplasmic sperm injection (ICSI) useful? (2 things)

Answer 38

1. Sperm motility issues 2. Low sperm count