Infertility

Question 1

How is subfertility defined

Answer 1

Inability to conceive after 2 years of regular, unprotected intercourse
Couples presenting before 2 years, advise to continue trying and return later. Exception to this is if women is older than 36 or hx of predisposing factors where couples should try to conceive 1 year before referral

Question 2

Primary infertility

Answer 2

Inability to conceive with no prior pregnancy

Question 3

Secondary infertility

Answer 3

Inability to conceive but prior pregnancy has occurred regardless of outcome of pregnancy

Question 4

Criteria for funding for assisted conception

Answer 4

BMI <30
No living children
<40 at time of treatment 
Both partners are non-smokers
No previous funded IVF treatment

Question 5

History taking in subfertility

Answer 5

How long they have been trying to conceive
Previous pregnancies or living children
Clarify details of past pregnancies and children
General health of both partners:
BMI
Smoking, alcohol, drugs
Full PMHx/PSHx including previous malignancies and treatment, STIs, chronic conditions, pelvic/genital trauma or surgery
Medication history e.g. atypical antipsychotics, immunosuppressants
Sexual history:
Frequency of coitus, ideally 2-3 times a week
Emotional or physical difficulties
Ejaculatory problems

Question 6

Main causes of female infertility

Answer 6

Disorders of ovulation

Problems with genital tract

Question 7

Ovulation disorders

Answer 7

• Hypothalamic pituitary failure
  o Hypothalamic amenorrhoea e.g. low BMI, chronic disease, excessive exercise
  o Hypogonadotrophic hypogonadism e.g. pituitary tumours, Sheehan’s syndrome, hyperprolactinaemia
• Hypothalamic-pituitary-ovarian dysfunction
  o PCOS
• Ovarian failure
  o Premature ovarian failure
  o Chromosomal abnormalities e.g. Turner syndrome, testicular feminisation, trisomy X

Question 8

Problems with genital tract

Answer 8

• Tubal damage, particularly following genital tract infection (PID, postpartum infection, STIs) or local infection (appendicitis, peritonitis). Tubal damage can also occur due to previous surgery
• Uterine abnormalities
  o Asherman’s syndrome of the uterus
  o Deformity of the uterus e.g. bicornate uterus, fibroids
• Cervical damage from previous surgery
• Endometriosis

Question 9

Investigating subfertility in females

Answer 9

Assessment of ovulation is usually achieved by assessing hormone levels
- Mid-luteal progesterone (assessed 7 days before the next expected period), this should usually surge to >15
- Hormonal profile
o LH and FSH, measured day 2 – 4. High levels can suggest ovarian dysfunction, and low levels suggest central dysfunction
o Prolactin
o Testosterone
o Thyroid function where relevant
Secondary care investigations include
- USS of the genital tract to look for structural abnormalities
- Assessment of tubal patency
o Hysterosalpingogram
o Laparoscopy and dye test
- Ovarian reserve testing, undertaken on day 3 of the cycle
o Total antral follicle count, measured by TV-USS
o AMH level
o FSH level

Question 10

Causes of male infertility

Answer 10

problems with spermatogenesis or problems with the genital tract

Question 11

Disorders of testis and spermatogenesis

Answer 11

• Hormonal abnormalities
  o Hypothalamic or pituitary dysfunction e.g. hyperprolactinaemia, pituitary tumours, panhypopituitarism, Kallman syndrome
• Testicular abnormalities
  o Cryptorchidism, leading to testicular dysgenesis
  o Acquired abnormalities e.g. varicocele, testicular tumours, trauma, orchitis
  o Genetic abnormalities e.g. Kleinfelter’s syndrome

Question 12

Problems with male genital tracts

Answer 12

• Obstruction in the epididymis, ejaculatory, or seminal ducts
  o CF (congenital bilateral absence of the vas deferens)
  o Previous STI
• Non-obstructive
  o Ejaculatory dysfunction
  o Retrograde ejaculation

Question 13

Semen Analysis

Answer 13

initial investigation in males, and should be repeated after 3 months if abnormal. 3 days of abstinence prior to sampling is best
Look at volume, pH, sperm concentration, total sperm number, sperm motility, sperm vitality, wbcs, antibody coated, morphology

Question 14

How is male ejaculate graded

Answer 14

• Normozoospermic is where every aspect of the semen meets the WHO parameters
• Oligozoospermic is a low sperm count, <15 million spermatozoa per ml
• Asthenozoospermic is a low sperm motility, <32% of sperm with rapid forward progression
• Teratozoospermic is low sperm morphology, <4% spermatozoa with normal morphology
• Azoospermic is an ejaculate that contains no spermatozoa