Infertility

Question 1

What are the main causes of infertility?

Answer 1

1) Male Factors (30%)
2) Ovulatory (25%)
3) Unexplained factors (25%)
4) Tubal (20%)
5) Uterine/peritoneal (10%)

Question 2

When should a couple be referred due to infertility issues?

Answer 2

When they have attempted to naturally conceive for over 1 year

Question 3

What would make you consider early referral for investigating infertility?

Answer 3

Woman: >35, menstrual disorder, previous surgery, previous PID/STI
Man: Genital pathology, previous STI, systemic illness or abnormal genital examination

Question 4

What pre-conception advice would you give to a couple?

Answer 4

Have intercourse 2-3 times a week.
Folic acid.
Ensure smears are up to date.
Smoking cessation and reduce alcohol intake.
Manage co-morbidities.
Ensure healthy weight.

Question 5

What reproductive disorders are associated with obesity?

Answer 5

1) PCOS
2) Miscarriage
3) Infertility
4) Obstetric complications

Question 6

What 3 things are investigated in initial infertility tests?

Answer 6

Ovulation.
Semen quality.
Tubal patency.

Question 7

Infertility investigations: what initial tests would the GP do?

Answer 7

Hormone profile (D2, FSH, D21 progesterone).
TFT’s.
Rubella.
Smear.
Semen analysis.

Question 8

Infertility investigations: how can you check ovulation?

Answer 8

Measure mid-luteal progesterone.

Question 9

Infertility investigations: what hormone levels are looked at in order to test ovarian reserve?

Answer 9

FSH.
AMH
AFC (antral follicle count) is also determined through imaging.

Question 10

A sperm count less than what will indicate the need for clinical examination and further tests?

Answer 10

<5m/ml.

Further testing may include endocrine tests and karyotyping e.g. klinefelters.

Question 11

Infertility investigations: how can tubal patency be investigated?

Answer 11

HSG (hysterosalpingogram) imaging.
HyCoSy (Hysterosalpingo-contrast-sonography).
Laparoscopy.

Question 12

How can infertility be managed if there is a mild abnormality?

Answer 12

Intrauterine insemination.

Question 13

How can infertility be managed if there is a moderate abnormality?

Answer 13

IVF

Question 14

How can infertility be managed if there is a severe abnormality?

Answer 14

Intra-cytoplasmic sperm injection.

Question 15

How can infertility be managed if azoospermia is the cause?

Answer 15

1. Surgical sperm recovery.
2. Donor insemination

Question 16

Infertility: Give 3 risk factors for anovulation.

Answer 16

Stress.
Low weight.
Extreme exercise.
Kallmann’s + Turner’s syndrome.

Question 17

What is the rotterdam diagnostic criteria for PCOS.

Answer 17

Anovulation/oligomenorrhoea.
Polycystic ovaries seen on imaging.
Increased androgens - clinically or biochemically.

Question 18

How can PCOS be treated?

Answer 18

Encourage weight loss.
COCP if not wanting to get pregnant.
Symptomatic treatment of acne and hirsutism.
For pregnancy:
Clomifene/tamoxifen.
Metformin.
Ovarian drilling.

Question 19

How does Clomifene work in the treatment of PCOS?

Answer 19

Clomifene is an anti-oestrogen. It leads to increased production of LH/FSH and so there is more follicle stimulation. It can treat menstrual disturbance and has a good pregnancy rate.

Question 20

Infertility: give 3 causes of tubal disease.

Answer 20

1) Infections.
2) Endometriosis.
3) Iatrogenic e.g. following surgery.

Question 21

Outline the process of IVF

Answer 21

Ovarian stimulation -> egg collection -> insemination -> fertilisation check -> embryo culture -> embryo transfer -> luteal support.

Question 22

Why is only 1 egg utilised in IVF?

Answer 22

To avoid multiple pregnancies

Question 23

Give 4 risks associated with IVF.

Answer 23

Multiple pregnancy.
Miscarriage.
Ectopic pregnancy.
Foetal abnormality.

Question 24

Give 4 factors that can affect the likelihood of IVF being successful.

Answer 24

Increasing age -> reduced egg quality.
Successive cycles/longer duration infertility.
Obesity.
Environmental factors e.g. smoking, alcohol, caffeine.

Question 25

Give 3 examples of uterine abnormalities that can affect fertility.

Answer 25

Endometrial polyps.
Fibroids e.g. sub-mucous will significantly affect pregnancy rates.
Adhesions.