Infertility

Question 1

At what age does fertility rapidly start to decline in females?

Answer 1

35yrs

->peak fertility is between 20-30yrs

Question 2

What happens to fertility with age?

Answer 2

Declines with age

->quantity and quality of eggs decreases

Question 3

What are the key factors which need to be working efficiently for conception of a child to take place?

Answer 3

Ovulation
Sperm production
Fertilization
Implantation

Question 4

List some of the lifestyle factors associated with infertility.

Answer 4

Age
BMI
Smoking
Alcohol
Recreational drug use
Stress

Question 5

Define infertility.

Answer 5

Inability to conceive over a 12 month period despite exposure to regular, unprotected intercourse

Question 6

When would you refer a couple for infertility investigations?

Answer 6

No conception after one year of regulated unprotected intercourse

Refer earlier if:
Age >35
Known cause for the infertility

Question 7

Primary infertility?

Answer 7

Couple have never managed to have a pregnancy or man has never fathered a child

Question 8

Secondary infertility?

Answer 8

Couple have had pregnancy before, in this or a previous relationship but are struggling to fall pregnant again

Question 9

Which investigations may be used to determine if eggs are available?

Answer 9

Ovarian reserve test- blood test and scan
Blood test- FSH, D1-D5 of cycle
AMH- anti-Mullerian hormone
Ultrasound scan - antral follicular count

->remember that age is a good indicator

Question 10

Which ways can couples determine if ovulation is happening?

Answer 10

Natural methods- Basal body temperature or cervical mucus
LH ovulation kits
Ovulation calendar e.g. mobile apps

Question 11

What is the one test which is used clinically to determine if a person is having ovulation?

Answer 11

D21 serum progesterone

-D21= day 21 of period, levels >21nm/L show satisfactory ovulation

Question 12

Per ml of sperm, how many are expected to be seen in a healthy individual?

Answer 12

15 million / ml

-if reduced, does not mean complete infertility but reduced chances

Question 13

Which methods can be used to check if the fallopian tubes are patent?

Answer 13

If no pelvic infection or gynae problems in the past = hysterosalpingogram (HSG)

If any of above= Laparoscopic dye test

Question 14

In addition to the previous tests, which routine tests are carried out in investigation of an infertile couple?

Answer 14

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

Also check rubella immunity and run a cervical smear update

Question 15

What is one of the most common reasons that someone would not be ovulating?

Answer 15

Polycystic ovaries

Question 16

First line management of ovulation disorders?

Answer 16

Optimise body weight
Healthy lifestyle
Exercise

Question 17

Which medications may be give for ovulation induction?

Answer 17

Clomiphene citrate
Gonadotrophins

->clomiphene citrate works in most cases but direct hormones (gonadotrophins) are given as second line med

Question 18

If lifestyle measures and medication does not restore ovulation, what can be done?

Answer 18

Surgical- laparoscopic ovarian drilling

Question 19

Azoospermia?

Answer 19

Very low or no sperm

Question 20

Medical treatment for azoospermia?

Answer 20

Gonadotrophins

Question 21

What are the other options for someone with azoospermia if medical treatment does not work?

Answer 21

Surgical sperm retrieval from testes/epididymis
Donor sperm- intrauterine insemination
ICSI- intracytoplasmic sperm injection

Question 22

If there is a problem with fertility because of issues with the fallopian tubes, what can be done?

Answer 22

Surgery- limited to mild tubal disease
IVF

Question 23

If a women is infertile and has been found to have endometriosis, what can be done for treatment?

Answer 23

Ablation or resection of spots, adhesiolysis, cystectomy for endometrioma

Question 24

If a women is infertile and has been found to have uterine problems, what can be done for treatment?

Answer 24

Removal of polyp/fibroid, adhesiolysis for synechiae

Question 25

What is the final management of unresolved infertility?

Answer 25

IVF

Question 26

What is IVF?

Answer 26

In-vitro fertilisation
Oocyte is fertilised by sperm outside of the body

Question 27

What are the two egg options for IVF?

Answer 27

Use own eggs- gonadotrophin induced superovulation

Donor eggs if:
-patient is of increased age,
-eggs of are poorer quality,
-there has been ovarian failure
-genetic cause which will be passed onto foetus

Question 28

What are the two sperm options for IVF?

Answer 28

Use own sperm- fresh sample of the day or frozen

Donor sperm if:
-single mother
-same sex relationship
-azoospermia
-genetic cause
-infection e.g. HIV, HepB, HepC

Question 29

What are the two fertilisation techniques which may be used in IVF?

Answer 29

Insemination
Intracytoplasmic sperm injection

Question 30

Embryo transfer is done under which imaging technique?

Answer 30

Ultrasound

Question 31

How long after the embryo transfer can a pregnancy test be taken?

Answer 31

Two weeks after

Question 32

After the embryo transfer in IVF, what happens after a positive pregnancy test?

Answer 32

Scan at 7wks

Question 33

Risks of IVF?

Answer 33

Ovarian hyperstimulation syndrome (OHSS)
Multiple pregnancies
Medication side effects
Procedure related risks

->OHSS and multiple pregnancies are most common