Infertility

Question 1

Define infertility

Answer 1

The inability to conceive after 12 months of regular, unprotected intercourse

Question 2

What is primary infertility?

Answer 2

When there has been no pervious pregnancy

Question 3

What is secondary infertility?

Answer 3

Had pregnancy previously from current or previous relationship

Question 4

What percentage of couples in the general population will conceive within 1 year if the woman is less than 40?

Answer 4

80%
50% of the remaining will conceive in second year (ie 90% of total)
95% at 3 years

Question 5

Are women born with a finite number of oocytes?

Answer 5

Yes : 1-2 million

Approx 400,000 at puberty

Question 6

How many oocytes do women approx have at menopause?

Answer 6

Less than 1000

Question 7

How many mature oocytes are released during reproductive life?

Answer 7

Around 500

Question 8

Decline in fertility is directly related to…

Answer 8

Reducing oocyte population and egg’s inherent quality

Question 9

There is a small fall in fecundity rates from …

Answer 9

Approx 31 years old

Question 10

When is there a pronounced fall in fecundity rates ?

Answer 10

From 37 and steep fall after 40

Question 11

As a women gets older, there is an increased risk of…

Answer 11

Spontaneous miscarriage

Genetically abnormal offspring

Question 12

What causes of infertility are there?

Answer 12

Ovulation defects 25% 
Male factor 30%
Tubular disease 20% 
Unexplained 25%
Endometriosis (small percentage)
Uterine factors (small percentage)

Question 13

What might anovulation by caused by?

Answer 13

PCOS
Weight related: BMI>30 or <18
Ovarian failure - natural or secondary to chemotherapy or RT
Hyperprolactinaemia

Question 14

What can cause tubal disease?

Answer 14

PID
Pelvic surgery
Endometriosis
Anything that blocks the tubes and their function

Question 15

What should be discussed during history (female)?

Answer 15

Age
Duration of infertility
Have they had previous pregnancies, does either partner have children
Menstrual cycle - regularity, flow, associated pain, IMB, PCB
History of STIs
Previous surgery, especially tubal or for ectopic pregnancy
ask about smoking and alcohol (both reduces fertility)

Question 16

What should be done on examination (female)?

Answer 16

BMI - obesity has adverse effects on fertility
Body hair distribution, acne - signs of hyperandrogenism
Galactorrhoea
If history of primary or secondary amenorrhoea, check secondary sexual characteristics
Pelvic examination and speculum - take swabs and do cervical smear if due

Question 17

What should be discussed during history (male)?

Answer 17

General health
Alcohol and smoking - both affect sperm quality
Previous surgeries especially hernia., undescended testes
Previous infection e.g mumps, TB
Sexual dysfunction - erectile, ejaculatory

Question 18

What should be done on examination (male) if necessary?

Answer 18

Scrotum for varicocele
Testicular size and position
Prostate for chronic infection

Question 19

What baseline investigations should be done in primary care?

Answer 19

Follicular phase: LH, FSH (day 2-4) 
Luteal phase progesterone (day 21)
Rebella status
Cervical screening if not done
Chlamydia screening (before checking tubal patency to precent ascending infection) 

Depending on history:
Prolactin level
TFTs
Testosterone/ SHBG

Question 20

What secondary care tests should be done?

Answer 20

Pelvic USS prior to laparoscopy if suspecting ovarian pathology or uterine abnormality

Testing for tubal patency:
Hysterosalpingography HSG - she injected through cannula in cervix to demonstrate uterine anatomy - radiological images taken
Or laparoscopy and dye test (gold standard for assessing tubal patency) - methylene blue dye injected through cervix whilst tubes visualised with a laparoscope

Question 21

When should a diagnostic lap and dye test be done?

Answer 21

Used first line if strong suspicion of tubal abnormality or need laparoscopy for other reasons.
- previous PID history, endometriosis or previous surgery

Used second line if HSG abnormal

Question 22

What baseline investigations should be done for men?

Answer 22

Semen analysis x2
If abnormal : make lifestyle changes e.g reduce/ stop smoking and alcohol and repeat after 3 months

If aspermia or oligospermia :
FSH, LH, testosterone
USS - seminal vesicles and assess prostate

Question 23

In terms of management, what lifestyle factors should be addressed?

Answer 23

Weight loss if necessary
Healthy diet
Stop smoking and recreational drug use
Reduce alcohol to less than recommended limit
Regular exercise
Folic acid (woman)
Regular intercourse every 2-3 days
Avoid ovulation monitors - stress and no evidence for benefit
Couples who time intercourse for day of ovulation might be too late, ideally there should be some sperm available for whenever fertilisation occurs

Question 24

What methods are there for ovulation induction?

Answer 24

Weight loss or gain
Clomifene citrate 50mg days 2-6 of cycle
If not suitable or unsuccessful: gonadotrophins (pulsatile GnRH)

Question 25

How is hyperprolactinaemia treated?

Answer 25

Dopamine agonist

Question 26

How can tubal disease be treated?

Answer 26

Surgical techniques - reconstruction, catheterisation

IVF

Question 27

What are the indications for IVF?

Answer 27

Tubal disease
Male factor subfertility 
Endometriosis 
Anovulation not responding to Clomifene 
Due to maternal age 
Unexplained for more than 2 years

Question 28

If infertility is due to male factor what can be done?

Answer 28

IVF
Intracytoplasmic sperm injection (ICSI)
Donor sperm if aspermia

Question 29

When defining what is regular (for sexual intercourse) for those trying to get pregnant, what should you advise?

Answer 29

Every 2-3 days

Question 30

When is donor insemination used?

Answer 30

When the male partner has azoospermia with failed surgical sperm retrieval
High risk of transmitting a genetic disorder
High risk of transmitting HIV
Woman with no (male) partner

Question 31

What is intracytoplasmic sperm injection? (ICSI)

Answer 31

When sperm is taken out of ejaculate or surgically from testis or epididymis and injected directly into the egg

Question 32

When is ICSI used?

Answer 32

When semen parameters severely abnormal
Failed fertilisation has occurred with IVF cycles
Concern that genetic mutations (especially Y chromosome deletions) will be propagated by transmission to offspring

Question 33

When is intrauterine insemination used? (IUI)

Answer 33

In mild male factor subfertility
Coital difficulties - physical disability or psychosexual problem
If it’s not safe to have unprotected sex e.g HIV
Same sex couples

Question 34

What is the difference between IUI and IVF?

Answer 34

In IUI the highest quality sperm / donor sperm selected and injected into uterus where they are left to fertilise egg naturally.

In IVF the eggs are removed from the body and fertilised in the lab.
IUI less invasive procedure and involves fewer drugs.
IUI is less expensive than IVF, but also less successful

Question 35

When will IUI not be appropriate?

Answer 35

If blocked tubes, severe endometriosis, low quality eggs or low number,

Question 36

How does Clomifene work?

Answer 36

An anti oestrogen

Increased endogenous FSH via neg feedback to pituitary

Question 37

What is the multiple pregnancy rate with clomifene?

Answer 37

10%

Question 38

What side effects can clomifene cause?

Answer 38

Hot flushes
Labels mood
If severe headache or visual disturbance- stop immediately

Question 39

How many cycles should clomifene be used for?

Answer 39

6-12 cycles

Question 40

Before specialist prescribes clomifene, what should they confirm first?

Answer 40

Tubal patency
Semen count normal or near normal
BMI <30

Question 41

What cancer does clomifene have a possible link with?

Answer 41

Ovarian cancer

Question 42

When taking clomifene, what type of monitoring is required?

Answer 42

Follicular monitoring by US - risk of hyperstimulation