Infertility

Question 1

Define infertility, including primary & secondary

Answer 1

Infertility is failure to conceive after 12m of regular, unprotected sexual intercourse.

• Primary = couple has never been able to conceive
• Secondary = woman has previously been pregnant, regardless of outcome, & now is unable to concieve

Question 2

Understand common pathologies in subfertile individuals and partnerships

Answer 2

FEMALE Factors:
- Ovulation problems = HPO dysregulation (low FSH) = prolactinoma, pituitary tumour, high phys activity, anorexia / (norm FSH) = PCOS, obesity / Ovarian failure (high FSH) = iatrogenic (chemo, RT), infiltrative (tumours), physiological (age >45 or premature failure)

• Tubal problems = PID, endometriosis, past ectopic, prev pelvic surgery
• Uterine problems = fibroids, Asherman’s
• Cervical problems = stenosis, cervicitis

PARTNERSHIP Factors:
- not enough regular sex, frequency/timing/technique

MALE factors:

• Azoospermia, Oligospermia, motility, morphology
• Hypogonadism // Testicular dx (undescended, Ca, TB) // obstruction (e.g. vas)

Question 3

take a medical history and perform a clinical examination relevant to fertility

Answer 3

Female Hx

• past gyn hx: include sex dev, menarche, periods (irreg/reg), prev infections/gyn problems (esp stigmata endometriosis, PCOS), prev contraception (e.g. Depot provera), pap-tests/abnormal
• obs: prev pregnancies (incl ToP, miscarriages, ectopics), ever tried conceive, other partners
• Medical hx + meds
• Surgical Hx + allergies
• FHx
• Social: alco & smoking

Male Hx

• development
• sexual fn
• testicular trauma, descent, prev infections (epididymitis), varicocele, surgies (vasectomy)
• Med / Surg / Alco+smoking / Psyc

Partnership

• sexual intercourse: frequency, technique, timing
• sexual fn: pain sex, ejaculation problems, psyc issues, stress/anxiety

Question 4

understand useful tests used to assess aetiology of infertility

Answer 4

1) Hormones - FSH (high, norm, low), basal horm profile (FSH, LH, serum test, prolactin, TSH), urinary LH, ‘Luteal phase progesterone’ (measured 7d before menses, high result = indicator of ovulation)
- Anti-Mullerian Hormone measured as marker of ovarian reserve (help det dose needed for IVF)
2) Semen analysis - sperm count, conc, morphology, motility
3) Imaging- TVUS pelvic US & Hysterosalpingogram (contrast - tubes)
4) Screening
5) Genetic: anatomical factors like Mullernian abnormalities (congenital uterine abn)

Question 5

describe the interventions of IVF, ICSI and PGD

Answer 5

IVF = ‘in-vitro fertilisation’

1. SUPER-OVULATION (FSH/GnRH suppression)
2. INDUCE Oocyte Maturation
3. COLLECT Oocytes (US guided TV needle aspiration procedure)
4. FERTILIZATION in vitro +/- ICSI
5. Embryo CULTURE
6. Embryo TRANSFER
7. VITRIFICATION of excess embryos

ICSI = ‘intra-cytsoplasmic sperm injection’

PGD = pre-implantation genetic diagnosis

• Trophectoderm (D5 embryo) or blastomere (D3 embryo) cell sampling for genetic analysis of embryos
  - Mendelian Sydromes
  
  • Screening For Aneuploidy