Infertility

Question 1

Define Subfertility and compare its 2 categories

Answer 1

• Subfertility: Regular (every 2-3 days) unprotected sexy but unable to conceive within 1 year
• Primary Infertility: Never been pregnant
• Secondary Infertility: Previously pregnant but struggling to conceive again

Question 2

What percentage of causes of subfertility are unidentifiable?

Suggest 3 things you would ask in a history

Answer 2

25%

• Sexual history
• Menstrual history
• Medical history

Question 3

For both men and women, give 3 types of causes of Subfertility

Answer 3

Men;

• Pre-testicular
• Testicular
• Post-testicular

Women;

• Ovulatory disorders
• Uterine and peritoneal disorders
• Tubal damage

Question 4

List 3 types of Pre-testicular causes of Subfertility

Answer 4

• Endocrine (Affect the HPG axis)
• General health/ systemic illness
• Coital problems (ED, Ejaculatory disorders)

Question 5

Testicular causes of Subfertility are generally to do with sperm production/ storage

List 4 types of Testicular causes of Subfertility

Answer 5

• Genetic (Klinefelter syndrome)
• Infective (STIs)
• Vascular (Torsion, Varicocele)
• Antispermatogenic agents (Heat, drugs, radiation)

Question 6

List 2 types of Post-testicular causes of Subfertility

Answer 6

• Obstructive (Congenital/ acquired)

- Coital problems (ED, Ejaculatory disorders)

Question 7

List and describe 3 types of Ovulatory disorders than cause Subfertility

Answer 7

1. Hypothalamic-pituitary failure;
   - Failure of GnRH to act on Pituitary
2. Hypothalamic-pituitary-ovarian Dysfunction;
   - Failure of axis to respond appropriately to stimulation
3. Ovarian failure;
   - Failure of ovary to respond

Question 8

Give 2 examples of Hypothalamic-pituitary-ovarian Dysfunction leading to Subfertility

Answer 8

• PCOS

- Hyperprolactinaemia

Question 9

Give 2 examples of Ovarian Failure leading to Subfertility

Answer 9

• Early menopause

- Turner’s Syndrome

Question 10

List 3 types of Uterine and Peritoneal disorders than cause Subfertility

(Physical reasons why implantation isn’t possible)

Answer 10

1. Uterine fibroids
2. Mullerian Developmental Anomalies
3. Conditions where scarring/ adhesions have occurred

Question 11

List 2 Mullerian Developmental Anomalies that can lead to Subfertility

Answer 11

• Septation uterus

- Bicornuate uterus

Question 12

List 4 examples of Conditions involving scarring/ adhesion that can lead to Subfertility

Answer 12

• Endometriosis
• Abdominal surgery
• PID
• Asherman’s Syndrome (Scarring within uterus

Question 13

List 4 examples of Tubal Damage than cause Subfertility

Specifically affecting Fallopian tubes, disrupting Ovum transport

Answer 13

• Endometriosis
• Pelvic surgery
• Infection (Chlamydia)
• Ectopic pregnancy

Question 14

What might you examine in a male patient?

Answer 14

• Penis for structural abnormalities
• Scrotum
• Secondary sexual characteristics

Question 15

What might you examine in a female patient?

Answer 15

• BMI
• Hirsutism, Acne
• Secondary sexual characteristics
• Ab/ Pelvic/ Vaginal exam: Masses, tenderness, infection, vaginismus, uterus size or position etc

Question 16

Suggest 5 investigations for men with subfertility

Answer 16

• Semen analysis (Sperm count, motility, liquefaction studies)
• Blood tests (LH, FSH, Testosterone)
• USS of testes
• STI screen to rule out
• Karyotyping

Question 17

Suggest 5 investigations for women with subfertility

Answer 17

• Bloods (Thyroid function, PRL, LH, FSH, Progesterone)
• STI screen to rule out
• Pelvic USS
• Test to check tubal patency

Question 18

Generally, when can you refer a couple to secondary care?

Answer 18

• After 1 year of trying to conceive

Sooner if;

• Woman is older (than 36)
• Known reason/ risk factors for infertility

Question 19

What are 3 methods of treatment?

Answer 19

1. Surgical
2. Medical- Ovulation induction (e.g Clomifene)
3. Assisted reproductive techniques, ART (e.g IVF)