Infertility

Question 1

Define infertility?

Answer 1

inability to conceive after 12 months of regular intercourse without contraception

Question 2

Infertility affects what proportion of couples?

Answer 2

1:6

Question 3

Primary vs secondary infertility?

Answer 3

primary= never had a child
secondary= previously had a child but now unable

Question 4

Describe the causes of hypothalamic pituitary failure and how that causes infertility?

Answer 4

Causes include: stress, excessive exercise, low BMI, brain tumours, head trauma, Kallman syndrome (genetic isolated GnRH deficiency), drugs e.g. steroids and opiates
Problem with not producing enough GnRH or dysregulation in pulsatility
will have low FSH, LH and amenorrhoea

Question 5

Treatment of hypothalamic pituitary failure?

Answer 5

Should improve lifestyle factors e.g. gain weight

but ultimate treatment is pulsatile GnRH pump or FSH and LH daily injections

Question 6

What is the commonest reason for ovulatory problems?

Answer 6

Polycystic ovarian syndrome

Question 7

Hormone levels in PCOS?

Answer 7

normal GnRH and FSH, normal oestrogen usually, potential excess LH

Question 8

Menstrual issues in PCOS?

Answer 8

oligo or amenorrhoea (although can be normal)

Question 9

What is PCOS characterised by?

Answer 9

multiple small cysts within the ovary and by excess ovarian androgen production

Question 10

What is PCOS associated with?

Answer 10

obesity, hyperinsulinaemia, insulin resistance and increased risk of T2DM, hypertension, hyperlipidaemia and increased CVS risk

Question 11

Diagnostic criteria for PCOS?

Answer 11

2 or more of:

• clinical and/ or biochemical evidence of hyperandrogegism
• oligo/ anovulation
• polycystic ovaries on ultrasound scan

Question 12

General treatment of PCOS?

Answer 12

weight loss, treatment of acne and hirsutism, treatment of infertility

Question 13

Fertility treatment for PCOS?

Answer 13

OVULATION INDUCTION:

1st line is clomifene

2nd line is gonadotropin injections

3rd line is laparoscopic ovarian diathermy

Question 14

Describe clomifene as fertility treatment for PCOS?

Answer 14

1st line: used on days 2-6 of the cycle, 70-80% ovulate, 30-40% conceive, letrozole is similar and may become first line as it requires less monitoring

Question 15

Describe use of gonadotrophin injections for fertility treatment for PCOS?

Answer 15

2nd line: injections with recombinant FSH, 80% ovulate, 60-70% conceive but risks multiple pregnancy as well as hyperstimulation

Question 16

Describe use of laparoscopic ovarian diathermy for fertility treatment for PCOS?

Answer 16

3rd line: 80% ovulate and no multiple pregnancies but it does risk ovarian destruction

Question 17

Describe use of metformin for PCOS?

Answer 17

PCOS is linked to insulin resistance and metformin helps with that although the whole link and mechanism not really understood

metformin can improve clomifene resistance in those who don’t ovulate and make them more likely to conceive

Question 18

Premature menopause is defined as ______

Answer 18

menopause before the age of 40

Question 19

Hormones in ovarian failure?

Answer 19

Raised LH and FSH but decreased oestrogen

Question 20

Causes of ovarian failure?

Answer 20

Turner syndrome (one X chromosome missing), other genetic conditions, autoimmune failure, surgery, radio/ chemotherapy, unknown aetiology

Question 21

What therapy should someone with ovarian failure be on?

Answer 21

should be on combined HRT

Question 22

Fertility treatment for someone with ovarian failure?

Answer 22

depends on stage of menopause, if peri-menopausal may get egg donor and hormonal treatment to maintain pregnancy, also option to adopt or foster

Question 23

Describe some uterine or ovarian abnormalities which could cause infertility?

Answer 23

congenital uterine abnormalities
fibroids
endometrial polyps
hydrosalpinx (blockage of tube with serous or clear fluid)
ovarian cysts

Question 24

Define azoospermia?

Answer 24

no sperm in ejaculate

Question 25

Define asthenozoospermia?

Answer 25

% of progressive motile sperm below reference limit

Question 26

Define oligozoospermia?

Answer 26

total number/ concentration of sperm is below that of reference limit

Question 27

Define teratozoospermia?

Answer 27

% of morphologically normal sperm below the reference limit

Question 28

If there are abnormal semen parameters then _____

Answer 28

male should be examined and should check LH, FSH, prolactin, testosterone, karyotype, check for CF carrier (as this can cause abnormalities in vas deferent), Y micro deletions

Question 29

In male factors more than _________

Answer 29

50% of causes are unexplained

Question 30

In GP appointment what initial investigations are done?

Answer 30

IN FEMALE:

• day 21 progesterone to establish ovulation
• rubella immunity
• chlamydia screen
• ensure smear up to date
• if amenorrhoeic or cycle lasts longer than 42 days also follicular phase bloods (LH, FSH, E2 (oestrodial)) , testosterone SHBG (sex hormone binding globulin), FAI and prolactin

IN MALES:
diagnostic semen analysis

Question 31

Additional tests that may be done in female?

Answer 31

ultrasound scan

tests to look at tubal patency

Question 32

Criteria for NHS access to ART? (9)

Answer 32

Stable relationship 2y (incl same sex)
Female age <40yrs (<42yrs)
Female BMI 18.5 – 30
Non-smokers (at least 3/12 pre-treatment)
No biological child from at least one of the couple
No illegal / abusive substances (incl methadone)
Neither partner to have been sterilised
Duration unexplained infertility 2y
Up to 3 cycles treatment