infertility

Question 1

define infertility

Answer 1

Defined as the inability to conceive after 12 months of regular unprotected intercourse

Question 2

causes of infertility

Answer 2

Male factor (30%)
- failure of sperm production - previous radiotherapy, infection

fallopian tubes not patent

• infection
• endometriosis
• adhesions

Ovulation defects (25%)

• excessive exercise
• underweight
• hyperprolactinaemia
• PCOS
• premature ovarian failure

Unexplained infertility (25%)

Uterine factors

Question 3

female history for infertility

Answer 3

Age
Duration of fertility
Type of infertility
are periods regular?
previous ectopics/miscarriages/terminations?
excess body hari/acne/weight gain? PCOS
dysmenorrhoea/menorrhagia? ENDOMETRIOSIS

Hx of STIs
Tubal surgery/ PID

Pelvic surgery

Question 4

examination for infertility

Answer 4

BMI
Body hair distribution
Galactorrhoea
Secondary sexual characteristics
Pelvic – structural abnormalities
fixed or tender uterus

Question 5

male history for infertility

Answer 5

General health
Alcohol/smoking
Previous surgery
Previous infections
Sexual dysfunction – erectile/ ejaculatory

Question 6

male examination for infertility

Answer 6

Not essential in the absence of any relevant history
Scrotum – varicocele 
Testicular size
Testicular position – undescended testes
Prostate – chronic infection

Question 7

female baseline Ix and additional Ix

Answer 7

• Follicular phase LH, FSH and oestradiol early in the follicular phase (Day 2-6)
• Progestrone test - mid-luteal phase (D21)
• measure TSH, prolactin and testosterone if cycle is shortened, irregular, prolonged, progestrone indicates anovulation
• TVUS - fibroids, PCOS
• Rubella status
• Hep B surface antigen, Hep C antibody and HIV 1&2 antibody
• Tests of tubal patency
• Pelvic ultrasound scan (ovaries, uterine abnormalities)
• Hysteroscopy

           Testosterone/SHBG

Question 8

tests for tubal patency

Answer 8

Hysterosalpingography (HSG)

Diagnostic laparoscopy and dye

Question 9

male baseline Ix for infertility

additional Ix for infertility

Answer 9

semen analysis x2 2-3 days after abstinence repeated 6 weeks if abnormal

• FSH / LH / Testosterone
• Ultrasound – seminal vesicles, prostate

Question 10

Mx for anovulation

Answer 10

FIRST LINE
- Clomiphene citrate

SECOND LINE

• Gonadotrophins/Pulsatile GNRH
• Dopamine agonists (Hyperprolactinaemia)
• Weight loss/weight gain

Question 11

Mx for tubal diseases in fertility

Answer 11

surgery

IVF

Question 12

Mx if male has the issue

Answer 12

• In vitro fertilisation (IVF)
• Intracytoplasmic sperm injection (ICSI)
• Donor insemination

Question 13

what is endometriosis

Answer 13

Tissue resembling the endometrium lying outside the endometrial cavity

Predominantly found in the pelvis

Responds to cyclical hormonal changes and bleeds at menstruation

Question 14

what is adenomyosis

Answer 14

Presence of endometrial tissue within the myometrium

Diagnosed by histology after hysterectomy

Considered by some to be a separate entity

Question 15

aetiology of endometriosis

Answer 15

Retrograde menstruation (Sampson’s theory)

Coelomic metaplasia (Meyer’s theory)

Question 16

clinical presentation of endometriosis

Answer 16

• Secondary dysmenorrhoea
• Heavy periods
• Dyspareunia
• Lower abdominal pain
• (epistaxes, rectal bleeding, PCB)
• Little correlation between symptom severity and disease severity

Question 17

clinical examination of endometriosis

Answer 17

NAD
Thickened uterosacral ligaments
Fixed retroverted uterus
Uterine/ovarian enlargement
Forniceal tenderness
Uterine tenderness

Question 18

Diagnosis and Ix for endometriosis

Answer 18

Diagnosis made by laparoscopy

Active endometriosis – “powder-burn” spots, chocolate cysts

Inactive endometriosis – “scars”

Peritoneal defects

Question 19

medical

Answer 19

All hormonal medical therapies suppress ovulation
COCP
Continuous progestogen therapy (MPA)
GnRH analogues (nasal spray/implants) ± HRT “add-back” therapy
(Danazol)
Mefenamic acid/tranexamic acid

Question 20

surgical Mx of endometriosis

Answer 20

Laparoscopic – diathermy, laser

TAH + BSO
risk of bladder, ureteric, bowel injury
risk of subtotal hysterectomy
role of HRT

Question 21

when does progestrone level peak

Answer 21

7 days after ovulation has occured

Question 22

how long is luteal phase

Answer 22

14 days

Question 23

if progestogen
< 16nmol/l

16-30nmol/l

> 30nmol/l

Answer 23

repeat, if consistently low refer to specialist

repeat

indicates ovulation

Question 24

key counselling points for couples trying to get pregnant

Answer 24

• folic acid
• aim for BMI 20-25
• advise regular sexual intercourse every 2 to 3 days
• smoking/drinking advice

Question 25

role of clomifene

Answer 25

antioestrogen

• blocks oestrogen receptors in the hypothalamus + pituitary
• increases the release of LH and FSH

given on days 2 to 6 of each cycle to initiate follicle maturation

limited to 6 months use

Question 26

Role of gonadotrophin

Answer 26

daily sub cut injection of recombinant or purified urinary FSH and/or LH

stimulates follicular growth

when follicle reached approx 17mm in size - process of ovulation is artificially stimulated by injection of hCH or LH

Question 27

Sx of pituitary adenoma

Answer 27

galactorrhoea
menorrhagia
bitemporal hemianopia
diplopia

Mx
bromocriptine