Infertility

Question 1

When do couples receive an infertility referral?

Answer 1

After 12 months of trying with no success or;
period irregularity
relevant PMH
testicular problems
Abnormal tests
HIV/hep B
Anxiety
After 6 months of trying in over 35s

Question 2

What is asked in a female history?

Answer 2

Duration of infertility
Previous contraception and fertility
Previous pregnancies and complications
Menstrual history
PMH
Sexual history
Psych assessment

Question 3

What is looked at in a female exam?

Answer 3

Weight, height and BMI
Fat and hair distribution 
Galactorrhoea
ABdo exam
Pelvic exam- masses, relic distortion, fixed retroversion, tenderness

Question 4

What is asked in a male history?

Answer 4

Development- change in body hair or shaving frequency, testicular descent
Previous fertility
PMH- vasectomy, varicocele, testicular descent, chamo/radio
Occupational history
Sexual history
Previous investigations/treatment
Drugs and environment

Question 5

What is done on a male exam?

Answer 5

Weight, height, BMI
Fat and hair distribution
Abdo and inguinal exam
Genital exam

Question 6

What would a change in hair and fat distribution mean?

Answer 6

Problems with androgens- too much in females, too little in males

Question 7

What baseline investigations are done for females?

Answer 7

Rubella immunity
Chlamydia
TSH
Testing for ovulation

Question 8

Why is TSH tested for in females?

Answer 8

Subclinical hypothyroidism can cause issues with implantation

Question 9

How is ovulation tested for in a woman w regular periods?

Answer 9

Mid luteal phase progesterone

Take sample 7 days before expected period

Question 10

How is ovulation tested for with irregular periods?

Answer 10

Day 1-5 FSH, LH, PRL, TSH and testosterone

Question 11

What tests are done for women at the fertility clinic?

Answer 11

Pelvic US
Physical exams
Tubal patency test- HyCoSy or laparoscopy
Test for ovulation- mid luteal progesterone or FSH and LH

Question 12

What tests are done for males?

Answer 12

Computerised semen analysis

Question 13

What would be considered a low sperm count?

Answer 13

<15 million sperm/ml

<39 million sperm per ejaculation

Question 14

What is considered severe oligospermia?

Answer 14

<5 million sperm/ml

Question 15

What are the types of ovulatory disorders?

Answer 15

Group 1- hypo-gonadotrophin, hypo-gonadic
Group 2- normo-gonadotrophic, norm-oestrogenic
Group 3- hyper-gonadotrophin, hypo-oestrogenic

Question 16

What is the treatment of group 1 ovulatory disorders?

Answer 16

Optimise BMI

Reduce overexercise

Question 17

What is an example of a group 2 ovulatory disorder?

Answer 17

Polycystic ovary syndrome

Question 18

What is the diagnostic criteria for polycystic ovary syndrome?

Answer 18

2 of;
androgen excess
infrequent periods
US conformation

Question 19

What are the signs and symptoms of androgen excess in PCOS?

Answer 19

Hirsutism
Moderately raised testosterone
Acanthosis nigricans

Question 20

What is the treatment of PCOS?

Answer 20

Optimise BMI

Pharm- clomifene or gonadotrophins

Question 21

What is clomifene?

Answer 21

Selective oestrogen receptor modulator

Question 22

How does clomifene work?

Answer 22

Inhibits oestrogen receptos in hypothalamus, preventing negative feedback and leading to up-regulation of gonadotrophin, causing ovulation

Question 23

What is the dose and course of clomifene?

Answer 23

Start 50mg, and adjust up to 150mg as necessary

Give for up to 6 cycles

Question 24

What are the possible side effects of clomifene?

Answer 24

Ovarian hyperstimulation
Multiple pregnancy
Visual alterations
Vasomotor “flushes”

Question 25

What are the indications to give gonadotrophin in PCOS?

Answer 25

No ovulation on clomifene | Ovulation but no pregnancy on clomifene

Question 26

How many cycles can gonadotrophin be given for?

Answer 26

3-6 cycles

Question 27

What are the signs and symptoms of an androgen secreting adrenal tumour?

Answer 27

Hirsutism | Acanthosis nigricans

Question 28

What are the signs and symptoms of fibroids?

Answer 28

Pressure symptoms | Period problems

Question 29

What type of fibroids affect fertility the most?

Answer 29

Submucosal- alter implantation

Question 30

What are the common causes of female infertility?

Answer 30

``` Ovulatory disorders Androgen secreting adrenal tumour Prolactinoma Fibroids Endometriosis Tumours Sterilisation Unexplained ```

Question 31

What causes epididymitis?

Answer 31

STIs

Question 32

What are the conditions of male infertility re the vas deferens?

Answer 32

Cystic fibrosis mutations | Congenital bilateral absence

Question 33

What are the conditions of male infertility re testes?

Answer 33

Testicular maldescent | Varicocele- dilation in pam-uniform plexus of veins

Question 34

What is hypospadias?

Answer 34

Urethral meatus on penis not in usual location

Question 35

What are the causes of azoospermia?

Answer 35

Testicular- normogonadotrophic, hypogonadism, hypergonadotrophic Post testicular- iatrogenic, congenital, infective

Question 36

What is the commonest cause of hypogonadism?

Answer 36

Klinefelter syndrome

Question 37

What investigations are done for azoospermia?

Answer 37

History and exam FSH, LH, testosterone and prolactin Karyotype CF screen

Question 38

What is the management of azoospermia?

Answer 38

Surgical sperm retrieval