Infertility

Question 1

• A basic understanding of the female reproductive cycle
• Knowledge of history and examination of sub-fertile couple
• Knowledge of investigation pathways in male and female infertility
• An understanding of treatment options in male and female infertility
• An introduction to the technology of assisted conception

Answer 1

.

Question 2

Infertility is defined as inability to conceive after how long of trying

Answer 2

12 months

Question 3

Questions to ask an infertile female

Answer 3

Duration of infertility
Contraception used in the past
Fertility in previous relationships
Previous pregnancies
Menstrual history - last period, frequency, regularity etc
PMH
Sexual history 
Psychological assessment

Question 4

Examination of an infertile female

Answer 4

Weight
Height
BMI
Fat and hair distribution – any underlying endocrine problem
Galactorrhoea - milk secretion unrelated to breastfeeding
Abdominal examination
Pelvic examination

Question 5

Causes of hirsutism

Answer 5

Polycystic ovarian syndrome
Congenital adrenal hyperplasia
Cushing’s syndrome
Acromegaly

Question 6

Pelvic examination of females should look at what things

Answer 6

Masses
Tenderness
Any vaginal septum
Cervix abnormalities
Fibroids - use USS

Question 7

Baseline investigations for infertile females

Answer 7

Rubella immunity - must be immune to get fertility treatment
Chlamydia
TSH
If periods regular - mid-luteal progesterone
If periods irregular - day 1-5 FSH, LH, TSH, testosterone

Question 8

Baseline investigation for infertile male

Answer 8

Semen analysis

Question 9

How to assess whether females are ovulating or not

Answer 9

Frequency and regularity of menstrual cycle - if regular then likely ovulating

Serum progesterone in mid-luteal phase (usually day 21 or 28) to confirm ovulation even if cycles are regular

If cycles irregular

• serum progesterone later in the cycle
• FSH & LH

Question 10

Investigations for tubal occlusion

Answer 10

Hysterosalpingography (HSG) - XR

Hysterosalpingo-contrast-sonography (HyCoSy) - US

Laparoscopy - more accurate as above 2 are just screening tests

Question 11

Questions to ask an infertile male

Answer 11

Previous fertility

Any developmental problems
-cryptorchidism, loss of body hair

PMH

• infections - mumps, STIs
• chronic illnesses

Surgical history
-varicocele, vasectomy

Drug history
-alcohol, smoking, steroids, chemo etc

Sexual history
-sex drive, frequency of intercourse

Question 12

Examination of an infertile male

Answer 12

Weight
Height
BMI
Fat + hair distribution - look out for androgen deficiency
Abdo + inguinal examination
Genital examination
-testicular size (ideally 15+ml)

Question 13

When should the GP refer you to fertility clinic

Answer 13

After 1 year of trying
OR
If there's a problem with 
-period regularity
-PMH
-testicular problems
-HIV
-abnormal blood tests
-older age

Question 14

WHO classifies ovulation disorders into 3 groups

Answer 14

Group I: hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism)

Group II: hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome)

Group III: *ovarian failure (POI – premature ovarian insufficiency)

*term not used anymore

Question 15

How does polycystic ovary syndrome affects fertility

Answer 15

Failure to ovulate an egg each cycle or irregular ovulation

Question 16

Treatment options to induce ovulation if you have ovulatory disorders

Answer 16

Clomifene - block oestrogen receptors in AP leading to increased FSH secretion

Gonadotrophins - FSH injection
-only if clomifene doesn’t work or ovulation leads to unsuccessful pregnancy

Question 17

Treatment options for females with tubal factor infertility (diseases, damage, scarring or obstructions in thefallopian tubes. e.g. PID, STIs, endometriosis)

Answer 17

Salpingectomy (removal of fallopian tube) ideally before starting IVF

Question 18

Treatment options for male factor infertility (presence of abnormal semen parameters [semen volume, sperm concentration, motility, morphology of sperm] in themalepartner of a couple unable to achieve conception after 1 year of unprotected intercourse)

Answer 18

Hormone treatment - gonadotrophin

Assisted reproductive techniques

• Intra-uterine insemination
• IVF +/- intracytoplasmic sperm injection

Donor insemination

Question 19

Define azoospermia

Answer 19

semen contains no sperm

Question 20

Treatment options for females with unexplained infertility

Answer 20

DO NOT OFFER ORAL STIMULANTS, e.e. clomifene

Intra-uterine insemination

Question 21

List 4 types of infertility problems

Answer 21

Tubal factor infertility
Male factor infertility
Ovulatory disorders
Uxexplained infertility

If individual treatment doesn’t work then try IVF

Question 22

List assisted conception/reproductive techniques

Answer 22

Intra-uterine insemination -inserting sperm into uterus

IVF

Intracytoplasmic sperm injection (ICSI) - single sperm injected straight into a single egg in the lab and the resulting embryo is transplanted into uterus

Donor sperm of eggs

Question 23

3 features of polycystic ovary syndrome

Answer 23

Irregular periods – which means your ovaries do not regularly release eggs

Excess androgen – high levels of male hormones in your body, which may cause excess facial or body hair

Polycystic ovaries – ovaries become enlarged and contain many follicles that surround the eggs (despite the name, you do not actually have cysts)

Question 24

Treatment of those with polycystic ovary syndrome desiring fertility

Answer 24

Weight loss +/- metformin (to control weight)

Ovulation induction - clomifene (1st line), gonadotrophin (2nd line)

If all above fails –> IVF