Infertility

Question 1

What percentage of fertile couples will reach conception by 6 months and 12 months?

Answer 1

6 months - 80%

12 months - 90%

Question 2

Name 5 maternal factors that can influence fertility

Answer 2

Age
Development
Menstrual cycles - are they ovulating?
Previous contraception
Endometriosis
Sexual patterns
Co-morbidities - PCOS, previous chemo/radiotherapy, obesity, previous uterine surgery (Asherman’s syndrome)

Question 3

Name 5 paternal factors that can influence fertility

Answer 3

Age
Development
Sexual function
Testicular function - trauma, descent, torsion
Co-morbidities
Vasectomy
Production of sperm antibodies (often secondary to testicular trauma - allows access of immune system to sperm)

Question 4

Name 5 investigations that can be done to assess infertility

Answer 4

Want to determine if there’s sperm, an egg and that the meeting place (tubes) is favourable

Hormones - FSH, TFT, prolactin in woman, anti Mullerian hormone (biomarker of ovarian reserve), serum/urine ovulation tests (to prove there’s an egg)
Genetics - chromosome analysis; may have Y chromosome, but be phenotypically female, Turner syndrome, Fragile X
Imaging - look for anatomical factors (congenital - Mullerian abnormalities, acquired - compromised tubal patency (after infection?), endometriosis, fibroids, polyps)
Screening
Semen analysis - a/oligozoospermia, motility/morphology issues, sperm antibodies

Question 5

What hormone is useful to investigate in infertility? In general, what does a high and low level of this hormone indicate as to the cause of the infertility? Give 3 specific causes for both. What management is indicated in both cases?

Answer 5

FSH

High (indicates primary ovarian failure; no oestrogen to suppress FSH) - iatrogenic (chemo/radio), autoimmune (SLE, RA), genetic (Fragile X), idiopathic, physiological (menopause). Mx - IVF and oocyte donation.

Low (indicates hypothalamic-pituitary dysregulation) - malnourishment/stress/high physical activity, pituitary tumour, infiltrative disease (sarcoid, haemochromotosis), genetic (Kallman syndrome - failure of GnRH releasing neurons to develop). Mx - lifestyle modification (weight loss if obese), treat pituitary/thyroid pathology, ovulation induction (recombinant FSH, clomate - universal oestrogen antagonist; leads to increase in FSH but HPA must be working)

Question 6

Name 3 modifiable and 3 genetic factors that can lead to paternal infertility

Answer 6

Modifiable - hypogonadism, smoking, vasectomy, varicocoele, anabolic steroid use
Genetic - Klinefelters, CF (het or homozygous) - congenital absence of the vas (also leads to absence of seminal vesicles), Y chromosome Azoospermia factor (AZF) mutation (Y q deletion)

Question 7

How do you treat paternal infertility?

Answer 7

Intracytoplasmic sperm injection (ICSI - especially if reason is because of anti-sperm antibodies, or CF - sperm production is OK), donor sperm use (Klinefelter’s), microsurgery (FNA or open testicular biopsy) to extract sperm (Klinefelter’s - 50% of finding viable sperm)

Question 8

What are the 7 steps in IVF?

Answer 8

1. FSH/GnRH suppression to lead to super-ovulation (gets rid of suppressive factors of ovulation) - between 15-20 eggs/cycle
2. Induce oocyte maturation
3. Collect eggs via U/S-guided transvaginal needle aspiration
4. Fertilise eggs in vitro +/- intracytoplasmic sperm injection
5. Culture embryos and do pre-implantation genetic diagnosis (screen for abnormalities)
6. Transfer embryo at blastocyst stage into uterus
7. Vitrify (cryo-presevation) remaining embryos

Question 9

What is the main iatrogenic complication of IVF? What can it cause?

Answer 9

Ovarian hyperstimulation syndrome. Hyperactive corpus luteum releases vasoactive substances after transfer of embryo back into uterus = fluid extravasation = hypotension, peripheral oedema, DIC