Infertility

Question 1

Define infertility

Answer 1

Disease of the male or female reproductive system defined by failure to achieve pregnancy after 12 months or more of regular, timely sexual intercourse.
It can be classified as primary where there is an inability to have a pregnancy, or secondary where there is an inability to have a pregnancy after a previous successful conception

Question 2

What RF are associated with male infertility

What RFs are associated with female infertility

Answer 2

Male:
1) Medications
2) Medical hx or orchitis or crypto-orchidism (testicular pathology)
3) Inguinal/testicular surgery
4) Sedentary lifestyle
5) Heat-generating => Cycling, tight boxers
6) Environmental: Smoking, Drug use
7) Premature ejaculation

Female:
1) Weight & Age: Declines with increasing weight and age (due to irregularities in ovulation and increased proportion of abnormal oocytes)
2) Anovulation/oligo-ovulation: PCOS, Hyperprolactinemia, Hyper/hypothyroidism
3) Pelvic pathology: PID, surgery, congenital anomalies (e.g. Mullerian)
4) Unexplained

Both: Timing and frequency of sexual intercourse, knowledge of human reproduction (oocyte most receptive within 24 hours from ovulation)

Question 3

What are the normal values of Semen Analysis?

Answer 3

a) Volume (2-6ml)
b) Concentration (>15 million)
c) Motility (>40%)
d) Morphology (>4% normal)
e) Anti-sperm antibodies

Question 4

Give common causes of azoospermia

Answer 4

Pre-testicular: Genetic abnormalities, hormonal imbalances, CF
Testicular: Orchitis, crypto-orchidism, varicocele, trauma, radiation therapy
Post-testicular: vasectomy, congenital absence of vas deferens, obstruction

Question 5

When is progesterone taken in the investigation for infertility?

Answer 5

Progesterone is taken at day 21 of the cycle or 7 days before menses

Question 6

What does the Anti-Mullerian hormone assess

Answer 6

assesses ovarian activity

Question 7

What does the Hysterosalpingogram assess?

Answer 7

Assesses the contour of the endometrial cavity + patency of fallopian tubes

Question 8

What is the gold standard for assessing pelvic structures

Answer 8

Laparoscopy, dye insufflation of tubes + Hysteroscopy

Question 9

How would you investigate a couple presenting with infertility.

Answer 9

Detailed hx and exam
Male:
1) Semen Analysis: If abnormal, this is repeated in 3 months before moving on
a) Volume (2-6ml)
b) Concentration (>15 million)
c) Motility (>40%)
d) Morphology (>4% normal)
e) Anti-sperm antibodies

2) Further Testing: If oligo-azoospermia
a) Karyotype
b) y-microdeletion studies
c) CF screen (Azoospermia)
d) Full hormone profile (FSH, LH, Testosterone, TFTs

3) DNA fragmentation studies

Female:
1) Full hormone profile: (Pre-ovarian)
a) FSH, LH, E2 taken at 3rd day of menstrual cycle
b) Progesterone is taken at day 21 of the cycle or 7 days before menses
c) Prolactin and TFTs (If androgenic, add testosterone, DHEA, free androgen index)

2) Anti-Mullerian hormone (assesses ovarian activity) (ovarian)

Post-Ovarian
3) Hysterosalpingogram (Assesses the contour of the endometrial cavity + patency of fallopian tubes)
4) Assess pelvic structures (Laparoscopy, dye insufflation of tubes + Hysteroscopy)

Question 10

If you are explaining to a couple when they should have sexual intercourse, what will you tell them?

Answer 10

14 days before the start of the women’s period

Question 11

How do you track ovulation?

Answer 11

Day-21 progesterone
US tracking of follicle

Question 12

How would you manage infertility?

Answer 12

Conservative management:
- Encourage a healthy lifestyle (reduce smoking, BMI)
- Frequent sexual intercourse (3-4/week) esp. during mid-cycle
- Daily folic acid (0.4mg/day or 5mg if diabetic or obese)
- Anti-oxidant vitamin E for males

If anovulation: Ovulation induction (Clomiphene citrate, letrozole, FSH) with ultrasound tracking of follicle. hcg may be used to trigger ovulation if follicle>18mm on US

If tubal -> Adhesion -> Adhesiolysis
If endometriosis -> Laparoscopic coagulation/excision

ART - Assisted reproductive techniques

Question 13

What are the risks of ovulation induction?

Answer 13

Multiple pregnancy
OHSS
Premature ovarian insufficiency

Question 14

What are examples of ART?

Answer 14

Donor oocytes, sperm, gamete, embryo
IVF
ICSI
(Just dont say intrauterine insemination)

Question 15

Define and Explain the process of Intrauterine insemination
Success rate

Answer 15

It is the timed introduction of sperm into the uterine cavity
Highly motile sperm are extracted from a sample following preparation in a culture medium. These sperm are then introducted directly into the uterine cavity via a Fine Plastic Catheter! and aligned with natural ovulation or in conjunction with induction

Success rate = 20% per cycle

Question 16

What is IVF briefly?
What is the success rate?

Answer 16

Artificial reproductive technologies. Sperm and oocytes are mixed outside the cavity => In-vitro fertilization before the resulting embryo being transferred into the cavity and the rest are cryopreserved. The process involves ovarian stimulation, oocyte retrieval, insemination, embryo transfer and luteal support

Success is based on age: >50% in <35, 20% at 40

Question 17

What is ICSI?

Answer 17

Intracytoplasmic sperm injection (Best for male infertility)
The process involves ovarian stimulation, oocyte retrieval, insemination, embryo transfer and luteal support. Here, insemination involves the direct injection of a single sperm into an oocyte and the resulting embryo is transferred into the uterus

Question 18

What are the complications of ART?

Answer 18

Multiple pregnancy
Ovarian Hyperstimulation syndrome

Question 19

What is OHSS and explain the pathophysiology of it

Answer 19

Ovarian hyperstimulation syndrome is a life-threatening complication of ovulation induction which is precipitated by hcg administration. VEGF mediates this syndrome and is characterized by increased vascular permeability => leakage leading to
1) Ascites, pleural effusion (Can add to pre-eclampsia, ovarian pathology, and HF)
2) Pre-renal failure
3) Torsion

Question 20

What are the risk factors for OHSS?

Answer 20

Think what makes the dose appear more effective?
1) reduced BMI (higher dose/kg)
2) PCOS (ovaries already big)
3) Age <30 (more receptive)
4) Previous OHSS
5) Increased Oestrogen levels

Question 21

What symptoms are associated with OHSS in increasing severity

Answer 21

1) Abdominal pain (increasing with severity) eventually torsion
2) Nausea and vomiting
3) Bloating -> Acites -> Hydrothorax (pleural effusion)
4) Ovarian size
5) Increased hematocrit >45%
6) Hypoproteinemia (pre-renal failure)
7) Oligo-anuria
8) ARDS
9) Thromboembolism (due to increased oestrogen)

Question 22

How would you use the size of the ovaries to determine severity of condition?

Answer 22

Mild <8cm
Moderate: 8-12 cm
Severe: >12cm

Question 23

What investigations would you perform?
How would you manage the patient?

Answer 23

History and Exam (abdominal pain, nausea/vomiting, Ascites, pleural effusion)
FBC (increased hematocrit, increased WCC)
U&E (Renal dysfunction/electrolyte disturbance)
Urinary catheter (Oliguria/anuria)

Imaging:
US -> Enlarged ovaries, Ovarian torsion
CXR -> Pleural effusion

Management:
1) Monitor signs and symptoms via investigations above
2) Urinary catheter insertion
3) Thromboembolism risk (TEDs, LMWH)
4) Drainage of ascites fluid (paracentesis) and hydrothorax (Thoracocentesis)

Question 24

How would you prevent OHSS?

Answer 24

Monitoring follicles with US, discontinuing the cycle if concerning

Question 25

What are the contraindications of COCP use?

Answer 25

Question 26

What are the contraindications for progestogen-only?

Answer 26

Liver impairment, liver enzyme inhibitors, or hx of deranged LFTs

Question 27

What are the advantages and disadvantages of COCP use?

Answer 27