Infertility

Question 1

What are the female and male factors which are important in pregnancy?

Answer 1

Ovarian factors

Tubal peritoneal factors

Cervical Factors

Male Factors (Sperm issues)

Question 2

What are the ovarian factors which can contribute to infertility?

Answer 2

Ovulatory dysfunction

PCOS

Premature ovarian insufficiency

Hypothalamic amenorrhoea

Question 3

What are the tubal/peritoneal factors which can contribute to infertility?

Answer 3

Endometriosis
Pelvic adhesions
Prior ruptured ectopic
Prior tubal surgery

Question 4

What are the cervical factors which can contribute to infertility?

Answer 4

Cervical stenosis

Cervicitis

Question 5

What are the male factors which can contribute to infertility?

Answer 5

Idiopathic oligospermia

Varicolcele

Ductal obstruction (post vasectomy/infective epididymitis)

Question 6

What is a normal sperm density and motility?

Answer 6

More than 20,000,000 per ml of semen

More than 50% motile

Question 7

Define subfertile?

Answer 7

If conception has not occurred after a year of regular unprotected intercourse.

Question 8

What is the difference between primary and secondary infertility?

Answer 8

Primary female partner has never conceived

Secondary female may have previously conceived but pregnancy ended in miscarriage

Question 9

In which scenarios would you refer a couple that have been trying for less than a year?

Answer 9

Female greater than 35yo

Symptoms of endometriosis

Previous PID

Malignancy

Question 10

What proportion of infertility of are due to ovulatory, tubal and male issues?

Answer 10

Ovulatory 30%

Tubal 25%

Male 25%

Remaining is idiopathic + coital and cervical problems

Question 11

What are the primary causes of anovulation?

Answer 11

Primary: 
Primary ovarian failure
Turner's
Iatrogenic (surgery/chemo)
Gonadal dysgenesis

Question 12

What are the secondary causes of anovulation?

Answer 12

PCOS (responsible for 80% of anovulatory infertility)

Hyperthyroidism

Androgen secreting tumours

Hypothalamic causes:

• Kallman’s syndrome: GnRH secreting neutrons fail to develop
• Hypothalmic hypogonadism: commonly seen in anorexia nervosa

Pituitary causes:

• Hyperprolactinaemia (adenomas/hyperplasia)
• Hypopituitarism (tumour/trauma)

Question 13

What investigations should be done in primary care for a couple presenting with sub fertility?

Answer 13

Chlamydia screen

Day 21 progesterone (elevated levels indicate ovulation has occurred)

Baseline hormones day 2-5: FSH, LH, Prolactin and testosterone

Endocrine screen

Semen analysis

Question 14

What are the extra investigations which may be done in secondary care in a couple presenting with sub fertility?

Answer 14

Hysterosalpingography: radiological procedure in which radio-opaque dye is infected into the cervical canal.

Laparoscopy and dye test: gold standard test + other pelvic pathology can be diagnosed at the time.

Question 15

What are the potential management options in infertility?

Answer 15

Lifestyle:
Encourage healthy diet and exercise.
Take folic acid supplements.
Quit smoking and reduce drinking.

Antioestrogens: (clomifene): Aids fertility. S/e profile similar to menopausal symptoms. Increased likelihood of multiple pregnancies. Limited use to 6 cycles as increases risk of endometrial cancer.

Gonadotrophin: for hypothalamic hypogonadism

IVF

Treat any obvious underlying cause: PCOS, Endometriosis, Anorexia

Question 16

What is ovarian hyperstimulation syndrome (OHSS)?

Answer 16

Gonadotrophin over stimulation causing the follicles to become very large and painful.

It can cause:

• Hypovolaemia
• Electrolyte disturbances
• Thromboemblosim
• Pulmonary oedema

May also be linked to ovarian and breast ca

Question 17

What are the risk factors for developing OHSS and how can the risk be minimised?

Answer 17

Risk factors:

• Gonadotrophin stimulation (usually IVF may be clomifine)
• Over 35yo
• PMH of OHSS
• Polycystic ovaries

Prevention involves using the lowest effective dose of gonadotrophins

Question 18

Define the following terms: azoospermia, oligospermia, severe oligospermia, asthenospermia?

Answer 18

Azoospermia: no sperm are present

Oligospermia: less than 15 million/ml

Severe oligospermia: less than 5million/ml

Asthenospermia: low motility

Question 19

What are the causes of oligospermia?

Answer 19

Idiopathic 
Testicular Ca
Drugs (Nicotine and alcohol)
Varicocele 
Genetic (Klinefelter's XXY)

Question 20

What are the potential causes of azoospermia?

Answer 20

Idiopathic 
Steroid abuse
Hypogonadotrophic hypogonadism
Klinefelter's XXY
Infection (orchitis/chlamydia/gonorrhoea)
Cryptorchidism (undescended teste)

Question 21

What types of coital dysfunction should be considered in male infertility?

Answer 21

Phimosis
Retrograde ejaculation (diabetes, bladder neck surgery)
Failure in ejaculation (MS, spinal cord injury)

Question 22

Which medications may impact on male fertility?

Answer 22

Anti spermatogenic:

• alcohol
• anabolic steroids
• sulfasalazine

Antiandrogenic:

• Spiranolactone
• Cimetidine

Erectile dysfunction:

• Beta blockers
• SSRI’s
• Metaclopramide

Smoking also impacts fertility

Question 23

What is the medical treatment for hypothalamic hypogonadism?

Answer 23

GnRH

Question 24

What is the medical treatment for retrograde ejaculation?

Answer 24

Imipramine