infertility

Question 1

definition

Answer 1

Primary infertility refers to couples who have not become pregnant after at least 1 year having sex without using birth control methods.
Secondary infertility refers to couples who have been able to get pregnant at least once, but now are unable.

Question 2

female examination

Answer 2

• Weight
• Height
• BMI (kg/m2)
• Fat and hair distribution
o Hirsutism – increased testosterone (BAH)
• Galactorrhoea
o Increased prolactin impairs release of egg
• Abdominal examination
o Do not advocate this, usually do USS first.
• Pelvic examination
o

Question 3

Male examination

Answer 3

• Weight
• Height
• BMI (kg/m2)
• Fat and hair distribution
o Hypoandrogenism – a loss of libido, impotence, infertility, shrinkage of the testicles, penis, and prostate, diminished masculinization (decreased facial and body hair growth)
o Do you shave regularly?
o Gynaecomastia
♣ Klinefelter syndrome (hypogonadism & microorchidism – infertility)
• Abdominal and inguinal examination
• Genital examination
o Testes
♣ Cryptorchidism
• Hypospadias
• Testicular tumours (orchiopexy before puberty lower risk compared to after puberty)
• Reduced fertility even after orchiopexy
o Epididymis
♣ Epididymitis
• STDs – Chlamydia trachomatis, gonorrhoea
• NSTD
o Vas deferens
♣ CF patients & congenital bilateral absence of the vas deferens (CBAVD)
o Varicocele
o Penis – hypospadias

Question 4

when to refer?

Answer 4

•

NICE guidelines – 1 year after trying 
•	Unless there’s a problem
o	Period irregularity
o	Past medical history
o	Testicular problems
•	Abnormal tests
•	HIV/Hep B
•	Anxiety
•	Age
o	<35yrs (after 1year)
o	35 - 45yrs (after 6 months)
o	>45 yrs (little can be offered)
•	Baseline investigations
o	Female: 
♣	Rubella immunity
♣	Chlamydia – affects fallopian tubes 
♣	TSH 
♣	If periods are regular:
•	Mid luteal progesterone ( 7 days prior to expected period);
♣	If periods are irregular: 
•	Do day 1-5 FSH, LH, PRL, TSH, testosterone
o	Male: 
♣	Semen analysis

Question 5

investigations

Answer 5

o Tubal patency test

Question 6

PCOS

Answer 6

1) Androgen excess
o	Clinical (Hirsutism)
o	Biochemical (Testosterone)
      2) Infrequent periods
o	Anovulation
      3) Polycystic ovaries
o	Ultrasound shows classic necklace pattern 
•	Management: 
o	Treat underlying cause
o	Weight loss/gain
♣	BMI >18 and <35
♣	High BMI common cause of anovulation 
•	Note NHS does not treat individuals with BMI >30 
o	

Ovulation Induction
♣ Clomiphene
♣ Gonadotrophins injections

Question 7

Ovarian hyperstimulation syndrome:

Answer 7

• OHSS is divided into the categories mild, moderate, severe, and critical.
• In mild forms of OHSS the ovaries are enlarged (5–12 cm) and there may be additional accumulation of ascites with mild abdominal distension, abdominal pain, nausea, and diarrhoea.
• In severe forms of OHSS there may be haemoconcentration, thrombosis, distension, oliguria (decreased urine production), pleural effusion, and respiratory distress.
• It may occur after stimulation of the ovaries into superovulation with drugs such as hCG and human menopausal gonadotrophin. It is rare with Clomifene except in polycystic ovarian syndrome (PCOS).

Question 8

Male factors

Answer 8

•	Investigations for azoospermia: 
o	History & Examination
o	FSH, LH, Testosterone, Karyotype, PRL
o	CF screen – CBAVD
•	Hypo-gonadism: give gonadotrophins 
•	Hyper-gonadotrophic: FSH high, LH high, testicle size small. Seen commonly in Klinefelter 

Sexual problems   
•	Psychosexual counselling
o	Onward referral
•	Artificial insemination
o	Timed insemination at home
o	Intra-uterine insemination at clinic