Infertility

Question 1

Define infertility

Answer 1

Inability to conceive after 12m of regular unprotected intercourse

• Primary - never been preg
• Sec - had previous preg

Question 2

List the causes of female infertility

Answer 2

Ovulation defects (25%) = PCOS, hyperprolactinemia, hyper/hypothyroid, eating disorders

Uterine/cervical = polyps, shape, tumours, fibroids, endometriosis

Tubal disease (20%) = PID, endometriosis, adhesions

Primary ovarian insufficiency = early menopause (Turners)

Unexplained infertility (25%)
uterus

Question 3

What are the causes of anovulation?

Answer 3

PCOS
Weight
Ovarian failure
Hyperprolactinaemia
Antipsychotics

Question 4

What are the WHO types of anovulation?

Answer 4

1 - Hypogonadotropic Hypoestrogenic = low oestrogen, low FSH

2 - Normogenadotroic Normoestrogenic = normal oestrogen, normal FSH

3 - Hypergonadotropic hypoestrogenic (ovarian failure) = low oestrogen, high FSH

4 - Hyperprolactinamia = high prolactin

Question 5

What are the causes of PID?

Answer 5

Chylamdia, gonnorhoea, TB

Question 6

Outline the important questions to ask and signs to look for in a Hx and exam in a FEMALE with infertility

Answer 6

Hx = age, duration of fertility, type of infertility, menstrual cycle, tubal surgery/PID, menorrhagia/
dys/pelvic pain, pelvic pain

Exam = BMI, body hair distribution, galactorrhoea (high prolactin, PCOS), sec sexual
characteristics (turners syndrome), swab

Question 7

Outline the important questions to ask and signs to look for in a Hx and exam in a MALE with infertility

Answer 7

Hx = general health, alcohol/smoking, previous surgery/infection (childhood mumps), sexual dysfunction

Exam = scrotum (varicocele), testicular size (anabolic steroids)/position (undescended), prostate

Question 8

How is female infertility investigated?

Answer 8

Follicular phase LH, FSH (Day 2)

Luteal phase progesterone (D21)

Rubella status (2 MMR = -ve, if +ve give MMR otherwise get congenital abnormalities)

Tests of tubal patency

• Hysterosalpingography (HSG)
• Diagnostic laparoscopy and dye

Pelvic USS

Hysteroscopy

Prolactin level/TFTs

Testosterone/SHBG

Question 9

How is male infertility investigated?

Answer 9

Semen analysis x2 (normal, abnormal, asospermia)

FSH/LH/testosterone

US seminal vesicles, prostate

If aspermia - genetic testing, CF screening

Question 10

How is anovulation treated?

Answer 10

Clomiphene citrate

Aromatase inhibitors = alternative to clomifene for women with PCOS

Gonadotrophins/Pulsatile GNRH

Dopamine agonists (Hyperprolactinaemia)

Weight loss/weight gain
- Every kg lost = 5% increase of fertility

Question 11

How is tubal disease treated?

Answer 11

Surgery

IVF

Question 12

How is male infertility treated?

Answer 12

IVF (sperm added to egg, still needs to burrow in)

Intracytoplasmic sperm injection (ICSI) (sperm injected through egg wall)

Donor insemination

Question 13

Outline the mechanism of clomifene citrate

Answer 13

Selective oestrogen receptor modulator

Binds to oestrogen receptors in the hypothalamic arcuate nucleus, disrupting the negative feedback and augmenting GnRH prod. This, in turn, augments endogenous production of FSH, and ovulation is achieved

Question 14

List the causes of male infertility

Answer 14

Production/function = undescended testes, genetic defects, DM, chlamydia, gonorrhoea, mumps, HIV, varicocele

Delivery = premature ejaculation, CF

Environmental = radiation, smoking, alcohol, anabolic steroids, marijuana

Cancer + Tx