Infertility

Question 1

Chances of natural conception decline with increasing what?

Answer 1

Female age

Question 2

What are the chances of conception per cycle?

Answer 2

20% at peak

Question 3

What is there a predetermined number of in women?

Answer 3

Pre determined number of eggs-no new egg production following egg numbers which the female is born with

Question 4

What happens as the ovarian reserve is exhausted?

Answer 4

Cycle irregularity begins to start by age 45 & then over the next 5-7 years menopause is reached

Question 5

What is associated with the decline in egg number?

Answer 5

Decline in the quality of the eggs where the capacity of the egg to perform well in terms of nuclear and genetic material division also declines (important feature required to achieve a conception)

Question 6

Can a decline in fertility be predicted?

Answer 6

NO, to date there is no fertility test that can tell whether a woman can get pregnant and have a baby

Question 7

What are 4 key important factors for conception?

Answer 7

Ovulation=egg production cyclically

Sperm production=Good & swimming well to fertilise egg

Fertilisation=Sperm & egg to meet-happens in fallopian tube (patent & functioning well), no ejaculatory or projectile problems (sexual dysfunction) to allow adequate sperm into the female repro tract

Implantation=Uterus has to be normal

Question 8

What parts are crucial for ovulation to happen?

Answer 8

Functioning of the hypothalamus & pituitary gland & ovaries along with the hormones has to be normal for ovulation to happen

Question 9

What is the diagnostic test for ovulation?

Answer 9

Measure progesterone to show whether ovulation did happen in that cycle or not

Question 10

What happens to the hormone levels in ovulation?

Answer 10

LH surge mid cycle and after ovulation progesterone goes up

Question 11

What cycles are coordinated in a cyclical fashion?

Answer 11

Ovarian & menstrual cycles

Question 12

What uterine changes occur each month?

Answer 12

Generate an endometrium each month which is capable of having an implantation & pregnancy

Endometrial development under the effect of ovarian hormones

Question 13

Fertilisation-oestrogen plays a role and also along with progesterone plays a role in tubal transport and implantation. How does the embryo get into the uterine cavity?

Answer 13

Once the egg is fertilised it starts dividing into embryo

Muscular spasms drive the embryo into the uterine cavity where it implants

Endometrium is prepared under influence of hormones in order to receive the embryo & drive the process of implantation

Question 14

What 6 things does natural conception rely on?

Answer 14

Functioning hormonal axis and gonads

Ovarian reserve

Regular ovulation

Normal sperm production

Fertilization- egg and sperm interaction patent fallopian tubes

Normal uterine cavity for implantation

Question 15

What lifestyle factors can affect fertility?

Answer 15

Age
BMI
Smoking-can accelerate the decline in ovarian reserve
Alcohol
Recreational drug use
Stress

Question 16

What is the WHO clinical definition of infertility?

Answer 16

Inability to conceive over a 12 month period despite exposure to regular , unprotected intercourse. Represents a prognosis based approach and provides practical guidance on when to initiate investigations.

Question 17

Why are global infertility trends often unreliable?

Answer 17

Many different definitions (WHO (clinical), epidemiological, demographic definitions)-used inconsistently when calculating prevalence

Question 18

When should people be referred for fertility issues?

Answer 18

No conception after one year of regular unprotected intercourse

Referral earlier if-
- Age>35 years
- Known cause for infertility

Question 19

What is the difference between primary and secondary infertility?

Answer 19

Primary=never manage to have a pregnancy before or the man has never fathered a child

Secondary=couple have had a pregnancy before in this or in a previous relation but then have not managed to get pregnant

Question 20

What are some causes of female infertility?

Answer 20

• Ovulatory dysfunction
• Diminishing ovarian reserve
• Endometriosis
• Uterine factor
• Tubal factor

Question 21

What may cause male infertility?

Answer 21

• Problems in producing hormones for sperm production
• Blockage of sperm transport
• Erection & ejaculation problems
• Sperm production problems

Question 22

How is it checked that there are eggs available?

Answer 22

Age
Ovarian reserve test- blood test and scan

Blood test- FSH, D1-D5 of cycle (<10 iu/L)
AMH (5.0-25.0pmol/L)
USS- Antral follicular count

AMH=Anti-mullerian hormone – can be measured at any time in the cycle to give an indication of whether the ovarian reserve is satisfactory

Question 23

What investigations are used to check that ovulation is happening?

Answer 23

Used by couples-
natural methods(BBT, cervical mucus)
LH ovulation kits (measures peak that happens mid cycle)
ovulation calendar

Used to investigate-
D21 serum progesterone

D21-test done on day 21 of the cycle when it is expected that the hormone level will have reached a peak-any levels over 20 are suggestive of ovulatory cycles

Question 24

What are the natural methods used for ovulation detection?

Answer 24

Progesterone rise that happens post ovulation-slightly higher temps can be recorded

Cervical mucus discharge-maximum around the time of ovulation (looks quite thin & watery)

Question 25

How is ovulation diagnosed?

Answer 25

Progesterone levels taken at appropriate time - day 21 only if 28/30 day cycle

Levels > 20nmol/l show satisfactory ovulation

Question 26

What can be used to see if there is sperm available?

Answer 26

Semen analysis

If these parameters are below that it does not mean total infertility but it means reduced infertility

Question 27

What needs to be the case in order for the egg and sperm to meet

Answer 27

Intercourse - with no sexual difficulties (e.g. pain or discomfort that prevents regular intercourse or that the man doesn’t have any erection or ejaculation problems)

Patent fallopian tubes

Question 28

How is the patency of fallopian tubes checked?

Answer 28

If no pelvic infection or gynaecological problem in past- Hysterosalpingogram(HSG)

If any of above- Laparoscopic dye test

Question 29

How is a HSG taken?

Answer 29

Catheter, dye and a radiograph

Question 30

How is laparoscopy carried out?

Answer 30

Laparoscope to inspect pelvic organs then put in methylene blue dye & see the flow of that out of the tubes

Any additional minor procedures can be carried out at the same time as necessary

Question 31

What other tests could be carried out?

Answer 31

Serum prolactin
Thyroid function test
Chlamydia screening
Pelvic Ultrasound for uterine problems

Also check- Rubella immunity
Cervical smear up to date

Question 32

What are the potential broad category causes of infertility?

Answer 32

Female, male, combined or unexplained

Question 33

How are ovulation disorders managed?

Answer 33

Optimise body weight, Healthy life
style, Exercise

Medication (ovulation induction)
- Clomiphene citrate-6 cycles oral tablets
- Gonadotrophins

Laparoscopic ovarian drilling

Question 34

What are the options if there is a very low count or no sperm (azoospermia)?

Answer 34

Medical treatments- gonadotrophins

Surgical sperm retrieval- epididymis/testis

Donor sperm- intrauterine insemination

ICSI (intracytoplasmic sperm injection)

Question 35

What can be done in the cases of tubal problems?

Answer 35

Role of surgery is limited to mild tubal disease

IVF (blocked tubes removed to make IVF suitable for them)

Question 36

What are other treatments for 1) Endometriosis & 2) Uterine surgery?

Answer 36

Endometriosis-Ablation or resection of spots, adhesiolysis, cystectomy for endometrioma

Uterine surgery- removal polyp/fibroid, adhesiolysis for synechiae

Question 37

What is an option for unresolved infertility?

Answer 37

IVF (In vitro fertilisation)- egg (oocyte) + sperm=embryo

Question 38

What is the role of Human Fertilisation & Embryology Authority (HFEA)?

Answer 38

Regulatory authority
Licensing
Inspections
Forms - registration, treatment, outcome
Register

Question 39

What eggs can be used for IVF?

Answer 39

Own eggs-gonadotrophin induced superovulation

Donor eggs - age (poor ovarian reserve)
poor quality
ovarian failure
genetic cause

Question 40

How is sperm got for IVF?

Answer 40

Partner-
Fresh sample on day of egg collection
Frozen sample (thawed)from surgical retrieval or fertility preservation

Donor sperm- Single women
Same sex relationship
Azoospermia(no sperm)
Genetic cause
Infection (HIV, HepB,HepC)

Question 41

What are the key steps for the IVF process?

Answer 41

Controlled ovarian stimulation
Follicular monitoring
Timing ovulation
Egg collection
Lab fertilization-Insemination/ICSI
Incubation/ embryo development
Embryo transfer-done under US guidance
Progesterone support

Final injection of hCG hormone to trigger ovulation & then 36 hrs=egg retrieval (via transvaginal US)

Support is given in the form of vaginal pessaries to maintain the endometrium for pregnancy

Question 42

How are embryos frozen and stored for IVF?

Answer 42

Technique of freezing=vitrification (straws frozen in liquid nitrogen)- can be kept in the freezing for ~10 yrs – can use it when ready for subsequent cycles

Each embryo stored in labelled/colour coded ‘straw’

Question 43

In IVF what is done post embryo transfer?

Answer 43

Progesterone pessaries

Normal activity

Pregnancy test after 2 weeks

If positive- scan at 7 weeks

Question 44

What are the risks of IVF?

Answer 44

Ovarian hyperstimulation syndrome (OHSS)

Multiple pregnancy

Medication side effects

Procedure related

• Over response of the ovaries-can get production of multiple follicles which can give rise to symptoms
• Egg recovery-risk of bleeding or infection

Question 45

Are there any negative long term affects of IVF?

Answer 45

Children born- no difference as per short term data.

Risk of ovarian cancer not confirmed

Absolute risk to women and children low