Infertility

Question 1

Causes of infertility in women

Answer 1

Ovulatory
Tubal  - adhesions
STI
PID
Endometriosis
Fibroids esp submuosal
Drugs - cocaine, depot-injection, chemotherapy, spironolcatone
Increasing age
Pathologies - Cushings, thyroid, CAH.
Stress
Smoking, obesity, excess alcohol consumption.
Exposure to pesticides, metals, solvents.

Question 2

Causes of infertility in men

Answer 2

Spermatogenic failure
Genetic = Klinefelter’s syndrome, Kallman syndrome.
Obstructive azoospermia
Varicocele
Hypogonadism (excessive exercise, anabolic steroids)
Cryptochidism/un-descended testes.
Drugs - chemotherapy, sulfasalazine, anabolic steroids, cocaine.
Testicular germ cell tumour.
Stress, obesity, smoking, excess alcohol.

Question 3

Ovulation disorders causing infertility in females

Answer 3

Excess exercise, low BMI, Kallman’s syndrome = hypothalamic amenorrhoea.
Turner’s syndrome.
PCOS, hyperprolactinaemia = dysfunctional H-P-O axis.
Premature ovarian failure

Question 4

Causes of primary spermatogenic failure in men

Answer 4

Congenital = testicular dysgenesis, absent testes.
Acquired = trauma, testicular torsion, renal failure, surgery, testicular tumour.

Question 5

Klinefelter’s syndrome

Answer 5

XXY. Hypogonadism. Gynaecomastia, long arms, learning difficulties and infertility. Rx with androgen therapy.

Question 6

Kallmans syndrome

Answer 6

Hypogonadotropic hypogonadism
Lack of GnRH.
Poor sense of smell
Males - micropenis, undescended testes, no secondary sexual characteristics.
Females - amenorrhoea, poor breast development.

Question 7

Preconception advice

Answer 7

Weight loss to healthy BMI
Smoking and alcohol intake cessation
Smears are up to date
Good control of co-morbidities e.g. DM
Intercourse 2-3 times per week
Folic acid - 0.4mg

Question 8

When to investigate a couple for infertility

Answer 8

After 1yr of regular unprotected intercourse which has not resulted in conception.
Females: Over 36yrs, amenorrhoea, PID, STI, pelvic or abdo surgery, abnormal pelvic axam.
Males: STI, varicocele, abnormal genitalia exam, urogenital surgery, previous genital pathology.

Question 9

Investigations for female infertility

Answer 9

Mid-luteal phase progesterone (confirm ovulation, usually taken on days 21-28 of cycle)
Ovarian reserve testing - FSH, AFC, AMH
STI screen and Rubella.
Serum progesterone, LH and FSH, TSH, prolactin.

Question 10

Investigations for male infertility

Answer 10

Semen analysis, if abnormal repeat after 3months. Include count, motility, morphology.
STI screen

Question 11

Secondary care investigations for male infertility

Answer 11

Karyotype (Klinefelter’s)
Serum endocrine - LH, FSH, testosterone, prolactin.
Testicular biopsy.

Question 12

Secondary care investigations for female infertility

Answer 12

Tubal patency test via laparoscopy and dye test.

TVUS

Question 13

Management of female infertility

Answer 13

LIFESTYLE MODIFICATION
Medical - clomifene (anti-oestrogen), gonadotrophins, pulsatile gonadotrophin and dopamine agonist.
Surgical - tubal miscrosurgery, surgical ablation, laproscopic ovarian drilling for PCOS.
Assisted conception - intrauterine insemination, in vitro fertilisation, donors (oocyte, embryo).

Question 14

Management of male infertility

Answer 14

LIFESTYLE MODIFICATION (including looser underwear to reduce scrotal temp)
Intrauterine insemination
Intracytoplasmic sperm injection.
Surgical correction of obstruction in epididymis.
Donor insemination

Question 15

Risks of assisted conception

Answer 15

Ovarian hyperstimulation syndrome (life threatening!) Thirst, dehydration, abdo pain, decrease urine output, abdo swelling.
Ectopic pregnancy
Multiple pregnancy - eSET reduces risk.
Miscarriage

Question 16

Definition of recurrent miscarriage

Answer 16

3 or more miscarriages before 24 weeks gestation with same biological father.

Question 17

Risk factors for recurrent miscarriage

Answer 17

Advance maternal and paternal age.
Previous Hx of miscarriage.
Alcohol intake, smoking and caffeine consumption.

Question 18

Possible causes for recurrent miscarriage

Answer 18

Antiphospholipid syndrome
Thrombophilia
Uterine abnormality
Poorly controlled endocrine disorders e.g. thyroid disease and diabetes mellitus.
Parental chromosome abnormality e.g. Robertsonian translocation.

Question 19

Investigating and managing recurrent miscarriage

Answer 19

Antiphospholipid antibodies.
Karyotype
Pelvic USS and potential hysteroscopy.
Thrombophilia screening
Refer to specialist clinic and treat cause.

Question 20

Components of ovarian reserve testing

Answer 20

FSH
Antral follicle count
Antimullerian hormone

Question 21

Difference between primary and secondary infertility

Answer 21

Primary - never conceived before.

Secondary - couple have previously conceived.