Infertility

Question 1

When should you refer a couple to fertility services?

Answer 1

Refer after ONE year of trying and not conceiving

Earlier referral if over 35, menstrual disorder, previous abdo/pelvic surgery, PID/STD etc.

Question 2

What pre-conception advice should be given to couples?

Answer 2

sex 2-3 x a week, lose weight if BMI over 30, folic acid, smear tests, rubella testing if needed, stop smoking and drinking, manage pre-existing comorbidities, remove occupational azards eg heat to testes

Question 3

What are possible causes of infertility?

Answer 3

Women:
Group I: hypothalamic pituitary failure eg stress, weight loss, kallmans, sheehans, adenoma
Group II: hypothalamic-pituitary-ovarian dysfunction, eg PCOS
Group III: ovarian failure eg menopause
Group IV: problem tube/ uterus eg endometriosis, fibroid, PID, STI, tubal disease

men:
- Low sperm count
- stress/weight loss/ exercise
- Pituitary adenoma
- Kallman’s
- Endocrine causes

All: Psychosexual

Question 4

What ix should be done for a person with a penis?

Answer 4

• Semen –count, motility, morphology - repeat in 3 months with lifestyle changes if abnormal
• STI testing
• TFTs
• testosterone
• Prolactin
• Look at testicle size and secondary sex characteristics
• ask about Steroids
• Karyotype

Question 5

How is azoospermia diagnosed?

Answer 5

testicle biopsy.

Question 6

What causes azoospermia?

Answer 6

Could be caused by steroids, Kallmann’s, hypogonadism, chemo, obstructive reasons

Question 7

mx of male infertility

Answer 7

IUI –intrauterine insemination if minor
IVF –if moderate
ICSI –intracytoplasmic sperm injection if severe

For azoospermia can do surgical sperm recovery

Donor sperm

Surgery for correction of ependymal block or reverse vasectomy

Decrease heat around testicles , no steroids
Diet and exercise
Stop smoking and drinking and give supplements

Increase prolactin

Question 8

What is the pathophyiology of PCOS?

Answer 8

PCOS - PCOS is caused by insulin resistance –> hyperinsulinaemia –> excess LH receptors so brain keeps up high LH levels –> androgen excess production in ovararies –> released into blood and converted to estrodione by fat cells –> negative effect on FSH –> LH remains high and FSH low, so no LH surge for ovulation –> infertility

Question 9

What is the Rotterdam criteria?

Answer 9

2/3 diagnoses PCOS
TVS shows polycystic ovaries
Amenorrhoea/oligomenorrhoea
Raised androgens - seen clinically ie hirsuitism or acne or biochemically (androstendione)

(outside of this criteria you may also get obesity and acanthosis nigrans due to insulin resistance)

Question 10

What is the mx for PCOS?

Answer 10

lose weight!!
COCP to regulate cycles 
clomifene (up to 6 cycles) 
metformin
Laproscopic ovarian drilling 
Gonadotrophins

Question 11

How do clomifene and laproscopic ovarian drilling work on PCOS?

Answer 11

clomifene- anti-oestrogen so increases FSH

drilling- aim is to reduce LHand induce ovulation by punctiring an ovarian cyst

Question 12

What ix are done for people with vaginas who are infertile?

Answer 12

STI testing

Ovarian reserve testing: do FSH day 2, AFC (antral follicle count), AMH (antimullerian hormone- more AMH more follicles) (only do if periods irregular)

Ovulation checking- mid-luteal progesterone (i.e. day21 in cycle, 7 day before period starts) - Prog should be high.

Prolactin and TSH IF sx

Rubella and smears if needed

Tubal patency test via HSG (hysterosalpingograph)
–> laparoscopy and dye are gold standard for tubal patency

Also, can check testoesterone (high in PCOS)

USS for fibroids, polyps, PCOS

A comparatively high LH level relative to FSH level can occur in PCOS

Question 13

How does IVF work?

Answer 13

Stimulate eggs with GnRH and monitor with U/S -> collect eggs via needle -> inseminate and fertilise -> culture -> transfer (max 2) -> support luteum with progesterone

Question 14

How many cycles of IVF does the NHS pay for?

Answer 14

<40 3 cycles, >40 1 cycle

Question 15

What are the risks of IVF?

Answer 15

multiple pregnancy, miscarriage, ectopic

Question 16

What is the mx of infertility for people with vaginas?

Answer 16

Clomifene (an anti-oestrogen drug) is an effective treatment for anovulation and may be used in selected women.

Gonadotrophins (FSH, LH) may be offered to women with clomifene-resistant anovulatory infertility. They are also effective in improving fertility in men with hypogonadotropic hypogonadism.

Dopamine agonists for hyperprolactinaemia.

Surgical treatment of infertility includes:
Tubal microsurgery in women with mild tubal disease — tubal catheterization or cannulation improves the chance of pregnancy in women with proximal tubal obstruction.

Surgical ablation, or resection of endometriosis plus laparoscopic adhesiolysis in women with endometriosis.

Check if menopause (high FSH, needs donor egg)

Question 17

What is the purpose of day 2 AMH, FSH and AFC ix?

Answer 17

One of the following measures should be used (measured around Day 2/3 of the menstrual cycle) to predict the likely ovarian response to gonadotrophin stimulation in IVF:

Total antral follicle count of ≤4 for a low response and >16 for a high response.
Anti-Müllerian hormone of ≤5.4 pmol/L for a low response and ≥25.0 pmol/L for a high response.
FSH >8.9 IU/L for a low response and <4 IU/L for a high response.
A high response results in more mature follicles developing, leading to higher-than-average pregnancy rates.