infertility

Question 1

What is the definition of fertility

Answer 1

infertility is defined following 12 months duration of regular unprotected sexual intercourse without conception.2 Where the woman is >35 years of age, six months duration is sufficient.

Question 2

What important history should be taken for infertility?

Answer 2

It is important to see both partners.

• History from the couple should include information on her cycle and menstrual symptoms,
• past medical and surgical history and significant family history and drug and occupational history for them both.
• Time trying to conceive, frequency and timing of intercourse as well as sexual dysfunction is also important to ascertain.
• Specifically for a woman, it is important to check for an up-to-date Pap smear and she is on an appropriate folic acid supplement

Question 3

What would you do to investigate a couple with infertility?

Answer 3

• preconception screening
  
  • For the woman, this includes rubella, HIV, hepatitis B and C and syphilis serology. Varicella and pertussis immunity and chlamydia screening should also be considered
  • healthy weight management and nutrition
  • For the male, hep B, C, HIV
• female investigations:
  
  • ovulation
    
    • cycle regularity
    • mid-luteal serum progesterone measurement
  • hormones
    
    • if irregular or absent menstrual periods, assessing for hyperprolactinemia
    • thyroid function: Both overt and subclinical hypothyroidism are associated with an increased risk of unexplained subfertility as well as poorer late pregnancy outcomes. TPO antibody positive females also have a higher incidence of subfertility.
  • ovarian reserve
    
    • AMH
    • Antral follicle count
  • tubal patency
    
    • Laparoscopic tubal chromotubation (gold standard)
    • HSG
  • imaging
    
    • TVUSS-endometriomas, ovarian cysts, hydrosalpinges, leiomyomas and endometrial polyps
    • 3D TV USS: mullerian abnormalities
    • Saline sonohysterography can also be used for detection of intracavity anomalies.
  • surgery
    
    • laparoscopy +- hysteroscopy
    • looking for pathologies contribute to infertility (endometriosis, polyps, submucosal fibroids, hydrosalpinges) and treatment can significantly improve outcomes
• genetic investigations
  
  • CF screening: CF gene mutations are associated with causes infertility, such as congenital absence of the vas deferens.
  • +- karyotyping
• male investigations
  
  • Semen analysis
    
    • 2 analysis 6 weeks apart
    • If persistent abnormal semen analyses baseline hormone profile (FSH, LH and testosterone) to indicate a central or peripheral cause that can then direct further investigation in a treatment setting
• Another anwser:
• The following tests are useful in most couples with infertility:

●Semen analysis to assess male factors

●Menstrual history, assessment of luteinizing hormone surge in urine prior to ovulation, and/or luteal phase progesterone level to assess ovulatory function

●Hysterosalpingogram or sonohysterogram with a test of tubal patency such as hysterosalpingo-contrast-sonography to assess tubal patency and the uterine cavity.

●Assessment of ovarian reserve with day 3 serum follicle-stimulating hormone and estradiol levels, anti-Müllerian hormone, and/or antral follicle count.

●Thyroid-stimulating hormone.

In select couples, the following additional tests may be warranted:

●Pelvic ultrasound to assess for uterine myomas and ovarian cysts

●Laparoscopy to identify endometriosis or other pelvic pathology

Question 4

Describe normal semen analysis

Answer 4

Semen volume (ml)>1.5

Sperm concentration (106/ml)>15

Progressive motility (%)>32

Normal forms (%)>4

Question 5

what is the chance on conception

Answer 5

People who are concerned about their fertility should be informed that over 80% of couples in the general population will conceive within 1 year if:

• the woman is aged under 40 years and
• they do not use contraception and have regular sexual intercourse.

Of those who do not conceive in the first year, about half will do so in the second year (cumulative pregnancy rate over 90%).

Question 6

what is the chance of conception with IUI?

Answer 6

Inform people who are using artificial insemination to conceive and who are concerned about their fertility that:

over 50% of women aged under 40 years will conceive within 6 cycles of intrauterine insemination (IUI)

of those who do not conceive within 6 cycles of intrauterine insemination, about half will do so with a further 6 cycles (cumulative pregnancy rate over 75%).

using fresh sperm is associated with higher conception rates than frozen–thawed sperm. However, intrauterine insemination, even using frozen–thawed sperm, is associated with higher conception rates than intracervical insemination.

Question 7

what is the optimal Frequency and timing of sexual intercourse or artificial insemination

Answer 7

• People who are concerned about their fertility should be informed that vaginal sexual intercourse every 2 to 3 days optimises the chance of pregnancy.
• People who are using artificial insemination to conceive should have their insemination timed around ovulation.

Question 8

what is the affect of alcohol on fertility?

Answer 8

• Women who are trying to become pregnant should be informed that drinking no more than 1 or 2 units of alcohol once or twice per week and avoiding episodes of intoxication reduces the risk of harming a developing fetus.
• Men should be informed that alcohol consumption within the Department of Health’s recommendations of 3 to 4 units per day for men is unlikely to affect their semen quality.
• Men should be informed that excessive alcohol intake is detrimental to semen quality.

Question 9

What is the effect of smoking on fertility?

Answer 9

both active and passive smoking reduces fertility in women

and reduces sperm quality

both men and women should be advised cessation and referred

Question 10

caffinated beverages

Answer 10

nice guidelines: People who are concerned about their fertility should be informed that there is no consistent evidence of an association between consumption of caffeinated beverages (tea, coffee and colas) and fertility problems

Question 11

Effect of BMI on fertility

Answer 11

• women with BMI > 30
  
  • takes longer to conceive
  • losing weight increases chance conception
• Men BMI >30
  
  • likely have reduced fertility
• Women BMI <19
  
  • if irregular menstruation or not menstruating if increase body weight increase chance of conception

Question 12

what are the causes of infertility?

Answer 12

• Male factor (hypogonadism, post-testicular defects, seminiferous tubule dysfunction)
• Ovary:
  • Ovulatory dysfunction inc. hyperprolactinaemia
  • Oocyte ageing
• Tubal (blockage or other abnormalities) or pelvic adhesion
• Uterine: impaired implantation, either mechanical or due to reduced endometrial receptivity
  
  • Leiomyoma (submucosal or intracavity)
  • uterine anomalies
  • intrauterine adhesions
  • luteal phase defect (inadequate progesterone)
• Endometriosis
• Cervical factor
  
  • Congenital malformations and trauma to the cervix (including surgery) may result in stenosis and inability of the cervix to produce normal mucus
• Coital problems
• Genetic
  
  • most common aneuploidies associated with infertility are 45, X (Turner syndrome) in women and 47, XXY (Klinefelter syndrome) in men
• Unexplained

Question 13

WHO classification of anovulation (3)

Answer 13

1. Hypogonadotropic hypogonadal anovulation (hypothalamic amenorrhea)
   
   • low or low-normal FSH and low estradiol due to decreased hypothalamic secretion of GnRH or pituitary unresponsiveness to GnRH.
2. Normogonadotropic normoestrogenic anovulation
   
   • normal amounts of gonadotropins and estrogens. However, FSH secretion during the follicular phase of the cycle is subnormal. This group includes women with polycystic ovary syndrome (PCOS). Some ovulate occasionally, especially those with oligomenorrhea.
3. Hypergonadotropic hypoestrogenic anovulation
   
   • premature ovarian failure (absence of ovarian follicles due to early menopause) and ovarian resistance (follicular form)

• WHO also classifies separate category of Hyperprolactinemic anovulation
  
  • ​hyperprolactinemia inhibits gonadotropin and therefore estrogen secretion; they may have regular anovulatory cycles, but most have oligomenorrhea or amenorrhea. Their serum gonadotropin concentrations are usually normal.

Question 14

Cervical mucus

• changes
• function

Answer 14

1. changes:
   
   • menses; followed by no secretions for three to four days; followed by scant, cloudy, sticky secretions for three to five days; followed by abundant, clear, wet, stretchy secretions for the three to four days immediately before, during, and immediately after ovulation; and finally, no secretions for 11 to 14 days, at which time the next menstrual period begins.
2. Function:
   
   • Before ovulation, estradiol produced by the developing follicle stimulates the production of cervical secretions that facilitate passage of sperm through the cervix and lead to functional maturation of sperm (capacitation) so that fertilization of the ovum is possible
   • Following ovulation, progesterone produced by the corpus luteum causes an abrupt change in secretions, which then inhibit sperm migration and capacitation.

Question 15

How to detect if a women has ovulated?

Answer 15

1. mensutral charting
   
   1. if regular cycles 25-30 days most likely ovulatory (plus thin stretchy mucus at ovulation and PMS symtpoms)
   2. ovulation is ~14 days before onset of menses
2. Basal temp charting
   
   1. before gets out of bed each day.
   2. progesterone from corpus luteum potent effect on hypothalamus and body temp.
   3. Get a rise in body temp after ovulation 0.5 degrees(1-2 days after LH surge lasting 10 days)
3. Serum progesterone concentration —
   
   1. measurement of the serum progesterone level in the mid-luteal phase, 18 to 24 days after the onset of menses or seven days before the next menses are expected
   2. Normal mid-luteal phase progesterone levels are between 6 and 25 ng/mL. When a progesterone level is low (eg, 2 ng/mL), one option is to repeat the test in two to three days. If it is not rising, it likely indicates a luteinized, unruptured follicle. These follicles are partially luteinized and make progesterone, but they do not have a sufficient cell number or synthetic ability to make adequate progesterone to support the luteal phase.
4. Measurement of LH surge —
   
   1. The LH surge can be detected in either urine or serum samples. The LH surge appears in the urine within 12 hours after it appears in the serum; as a result, it can accurately predict ovulation and, therefore, the optimal time for intercourse. The rise in serum LH typically occurs approximately 36 hours before the oocyte is released from the follicle into the fallopian tube.
5. Pelvic ultrasonography —
   
   1. Identification of a periovulatory follicle on ultrasonography is another important tool for evaluating the menstrual cycle and ovulation. Ultrasonography can identify a large follicle as a round cystic structure that reaches a diameter of 16 to 30 mm prior to rupture and release of the oocyte.
6. ovarian reserve An early follicular phase (EFP) follicle-stimulating hormone (FSH) level, paired with an estradiol level, can help predict ovarian reserve if the assay used has been validated at the facility where it is used.