Infertility

Question 1

What is the definition of infertility?

Answer 1

The inability of a couple to conceive after twelve months of regular intercourse without use of contraception

Question 2

What would you ask the female during the history (infertility related)?

Answer 2

• Duration of infertility
• Previous contraception
• Fertility in previous relationships
• Previous pregnancies and complications
• Menstrual history
• Medical and surgical history
• Sexual history
• Previous investigations
• Psychological assessment

Question 3

Which examinations would you perform on the female?

Answer 3

Weight and height (and then BMI), fat and hair distribution, galactorrhoea, abdo exam and pelvic exam

Question 4

What are the signs of androgen excess?

Answer 4

Hirsutism and ancanthosis nigricans

Question 5

How is androgen excess investigated

Answer 5

Testosterone, DHEAS > 700, adrenal CT and 17-OH progesterone

Question 6

What would you look for on the female pelvic exam?

Answer 6

Masses, pelvic distortion, tenderness, vaginal septum and cervical abnormalities

Question 7

Which baseline investigations would you do for the couple?

Answer 7

Female: rubella immunity, chlamydia, TSH, if regular periods then mid luteal progesterone, if irregular then day 1-5 FSH, LH, PRL, TSH and testosterone
Male: semen analysis

Question 8

Which investigations would you do at the fertility clinic (female)?

Answer 8

Pelvic USS, physical exam, testing for ovulation, semen analysis repeat if required and tubal patency test

Question 9

Which investigation is used for suspected tubal and uterine abnormalities in women without comorbidities?

Answer 9

Hysterosalpinography

Question 10

What would you ask the male in his history?

Answer 10

• Developmental: testicular descent, changes in shaving frequency and loss of body hair
• Infections: mumps and STDs
• Surgical: varicocele repair and vasectomy
• Previous fertility
• Drugs/environmental: alcohol, smoking, anabolic steroids, chemo, raditiation and recreational drugs
• Sexual history: libido, frequency of intercourse and previous fertility assessment
• Chronic medical illness

Question 11

What would you examine in the male?

Answer 11

Weight and height (+BMI), fat and hair distribution, abdominal, inguinal and genital (epididymis, testes, vas deferens and varicocele) exam

Question 12

What is the cause of epididymitis?

Answer 12

STDs (chlamydia and gonorrhoea)

Question 13

What is a varicocele?

Answer 13

Dilation of the pampiniform plexus

Question 14

What effect does Klinefelter syndrome have on the testes?

Answer 14

Impaired spermatogenesis and testosterone deficiency with small testes and azoospermia

Question 15

When should a couple be referred to the infertility clinic?

Answer 15

• After one year of trying unless there is a problem
• Problems: period irregularity, PMH, testicular problems, abnormal tests, HIV/Hep B, anxiety and age (35-45yrs after 6 months)

Question 16

How do the WHO classify ovulation disorders?

Answer 16

• Group 1: hypothalamic pituitary failure
• Group 2: hypopathalamic-pituitary-ovarian dysfunction (predominately POS)
• Group 3: ovarian failure (POI)

Question 17

What advice should women with group 1 ovulation disorders be given and what can you offer them?

Answer 17

They can improve their chance of regular ovulation, conception and uncomplicated pregnancy by:

• Increasing their body weight if their BMI is less than 19
• Moderating their exercise levels if high

You can offer them pulsatile administration of GnRH or gonadotrophins with lutenising hormone activity to induce ovulation

Question 18

What are the features of polycystic ovary syndrome (POS)?

Answer 18

• Androgen excess: hirsutism and high testosterone levels
• Infrequent periods
• Polycystic ovaries on USS

Question 19

What are the management options for ovulatory disorders?

Answer 19

• Treat underlying cause
• Weight loss/gain (BMI >18 and <35)
• Ovualation Induction: clomifene or gonadotrophins)

Question 20

How does Clomifene work?

Answer 20

• Primary site of action is oestrogen receptors
• Secondary site is ovaries
• Mechanism: hypothalamus perceives a hypoestrogenic state causing the pituitary gland to release gonadotrophins

Question 21

What is the treatment for hydrosalpinges and why?

Answer 21

Salpingectomy before IVF - improves chances of a live birth

Question 22

What are the categories of azoospermia?

Answer 22

Testicular: normogonadotrophic, hypogonadism and hypergonadotrophic
Post Testicular: Iatrogenic, congenital and infective

Question 23

What investigations would you do for azoospermia?

Answer 23

History, examination, FSH, LH, testosterone, karyotype, PRL and CF screen