Infertility

Question 1

What is infertility?

Answer 1

The inability of a couple to conceive after 12 months of regular intercourse without the use of contraception

Question 2

What are the chances of conception?

Answer 2

80% of couples in the general populaiton will concieve within 1 year if :the woman is aged under 40 years and they have regular sex

Question 3

What key information are you wanting to find out from the infertility consultation?

Answer 3

Are eggs available?
Are sperm available?
Can they meet?
Can an embryo implant?

Question 4

What questions do you want to ask the woman abut female fertility

Answer 4

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

Question 5

What examinations do you carry out on the female?

Answer 5

Weight
Height
BMI
Fat and hair distribution
Galactorrhoea
Abdominal examination
Pelvic examination

Question 6

What is androgen excess?

How do you measure androgen excess?

Answer 6

increased male hormones in woman leading to increased hair distribution and acanthosis nigricans

Ferriman gallwey score (hair distribution)
through testosterone levels, 
DHEAS greater than 700mcg/dL
Adrenal CT 
17-OH progesterone

Question 7

What is assesed for on pelvic examination?

Answer 7

Masses
Pelvic distortion
Tenderness
Vaginal septum
Cervical abnormalitis
Fibroids (pressure symptoms, period problems, infertility)

Question 8

What baseline investigation should be carried out at the fertility clinic?

Answer 8

Rubella immunity
Chlamydia
TFT
Regular periods- mid luteal progesterone
Irregular periods o FSH,LH,PRL,TSH,Testosterone
Male partners semen analysis

Question 9

What investigations should be carried out at the fertility clinic?

Answer 9

Pelvic ultrasound
Physical examination
testing for ovulation
semen analysis repeat
tubal patency test- typically HyCoSy

Question 10

What history do you want from male patients?

Answer 10

Testicular descent
Change in shavign frequency
Loss of body hair
Mumps?
STD's
Surgical varicocele repair
Vasectomy
Previous fertility
Drugs (steroids, alcohol)
Libido
Frequency of intercourse
Previous fertility assessment
Chronic medical illness?

Question 11

What male examinations should be undertaken?

Answer 11

BMI
Fat and hair distribution
Abdominal and inguinal examination
Genital examination (Epididymis, Testes, Vas deferens, Varicocele)

Question 12

What is a varicoele?

How does it relate to infertility?

Answer 12

Dilation of the pampiformplexus of the spermatic veins in the scrotum. Most men with varicocele and presumptive ingertility have abnormal semen paramters including low sperm, concentration and abnormal

Question 13

What is klenefelter syndrome?

Answer 13

One of the most common causes of primary hypogonadism with impaired spermatogenesis adn testosterone deficicncy. May occur in 1 out of 500 males.

It is characterised by XXY, small testes and azoospermia (spunk with no sperm)

Question 14

When do you refer someone to the sexual fertility clinic?

Answer 14

Period irregularity
Past medical probelms
testicualr problems
Abnormal tests (HIV/HEP B)
Age <35 years after one year
>35 years after 6 months

Question 15

What are the different classes of ovulatory disorders?

Answer 15

Group I- hypothalmic pituitary failure
Group II- hypothalmic -pituitary-ovarian dysfunction
Group III- ovarian failure (POI)

Question 16

What are some treatment and investigations for Group I ovulation disorders?

Answer 16

Anovulatory disorders (without ovulation)
Lifestyle advice: Increase weight (BMI<19)
Moderate exercise levels
GRH oR GH with LH to induce ovulation

Question 17

What is Polycystic Ovary syndrome

Answer 17

Androgen Excess (hirsutism, high testosterone)
Infrequent periods (anovulation)
polycystic ovaries (on ultrasound)

Question 18

How do you treat group 2 ovulatory disorders

Answer 18

treat underlying cause
Weight loss/gain
BMI>18 and BMI,35
Ovulation induction- clomifene and gondotrophins

Question 19

Discuss clomifene therapy

Answer 19

Selective oestrogen receptor modualtor (stop oestrogen interacting with the pituitary)
Dose chice- 50mg-150mg days2-6
Monitoring through follicular scanning in the 1st cycle, 15% require a dose adjustment
Side effects include vasomotor and visual problems

Question 20

When do you treat ovulatory disorders with gonadotrophins?

What is the treatment?

Answer 20

When there is ovulation but no pregnancy
No ovulation with clomifene

FSH is given by injection for 3-6 cycles

Question 21

What is a hydrosalpinx?

Answer 21

A condition where the Fallopian tubes become blocked with fluid.

Question 22

How do you treat woman withhydrosalpinges?

Answer 22

Surgery before in vitro fertilisation treatment. Woman with hydrosalpingesshould be offered a salpingectomy before IVF treatment as this improves the chance of a live birth

Question 23

How do you treat infertility in those with endometriosis and fibroids?

Answer 23

Surgery v medical treatment

Reversal or sterilisation no longer availabel soconsider IVF

Question 24

What treatment options can you offer males with infertility?

Answer 24

Urologist appoint if appropriate
IVF/ICSI
Intra uterine insemination
reversal of vasectomy
surgical sperm retrieval
Donor insemination

Question 25

What investigations can be carried out for azoospermia

Answer 25

History
examination
FSH,LH, testosterone, Karyotype,PRL
CF screen
Surgical sperm retrieval (go into testis)

Question 26

How do you treat unexplained infertility?

Answer 26

Do not offer stimulation agents
Explain they must keep trying for 2 years before they qualify for IVF
Offer IVF after two years

Question 27

Explain the process of IVF?

Answer 27

Eggs harvested from ovary
Mature Eggs fertilised with sperm in the lab (intracytoplasmic sperm injection)
Embryo’s undergo a number of cell divisions (5 days)
Embryo’s are put into the uterus