Infertility and ART

Question 1

A couple presents with infertility. What are the *general* considerations at this first visit?

Answer 1

• Female factors
• Male factors
• Pre-pregnancy screening
• Folate supplementation

Question 2

What is the epidemiology of infertility between the sexes?

Answer 2

• Male 25-40%, female 40-55%, both in 10%, unexplained in 10%

Question 3

What are some female causes of infertility?

Answer 3

• Ovulation - hypothalamic/pituitary, POF
• Tubal - infection, surgery, endometriosis
• Uterine - Asherman’s, fibroids

Question 4

What are some male causes of infertility?

Answer 4

• Pre-testicular - hypothalamic/pituitary
• Testicular - genetic (Klinefelter’s), congenital (cryptorchidism), infection (orchitis), vascular (varicocoele (heat), torsion), drugs, chemotherapy, radiotherapy
• Post-testicular - obstruction, accessory gland infection
• Coital - erectile dysfunction, retrograde ejaculation

Question 5

Describe the history and examination trail you might consider in a female presenting with infertility

Answer 5

• History - menstrual, obstetric, gynae (especially STIs, endometriosis, PCOS)
• PHx (chemoradiotherapy, autoimmune conditions, chronic medical conditions), medications, alcohol, smoking, occupation
• Examination - height, weight, secondary sexual characteristics, testicular size and vas presence

Question 6

Describe the history and examination trail you might consider in a male presenting with infertility

Answer 6

• History - surgical procedures, learning disabilities
• PHx (chemoradiotherapy, autoimmune conditions, chronic medical conditions), medications, alcohol, smoking, occupation
• Examination - height, weight, secondary sexual characteristics, testicular size and vas presence

Question 7

Investigative screen for a woman presenting with infertility

Answer 7

• Confirm ovulation with day 21 progesterone
• FSH, LH, oestradiol, TSH, prolactin, PCOS screen
• TVUS
• Hysterosalpingogram
• Laparotomy

Question 8

What are the components of a PCOS screen?

Answer 8

• Free androgen index [increased]
• DHEAS [mildly elevated]
• Androsteneodione [mildly elevated]
• Sex hormone binding globulin [decreased]

Question 9

What might you suggest education-wise to increase fertility?

Answer 9

• Ovulate between day 10 and 16
• Egg lasts 0.5 days, sperm 4 days
• Sex every 2 days during fertile period
• Smoking, alcohol cessation
• Folate supplementation

Question 10

How might you treat anovulatory infertility?

Answer 10

• Hyperprolactinaemia - dopamine agonists
• PCOS - metformin, clomiphene, FSH (second-last resort), IVF (last resort)
  
  • Clomiphene, FSH, IVF more likely to cause multiple pregnancy

Question 11

How might you approach the treatment of male-factor infertility?

Answer 11

• Treat reversible endocrine cause/infectious cause
• ART
  
  • Artificial insemination
  • IVF
  • ICSI (best sperm selection for IVF)

Question 12

What is the success rate of IVF? What are the steps? What are some complications?

Answer 12

• 30-40%
• Steps
  
  • Controlled ovarian hyperstimulation - COC then daily FSH injections, ovarian monitoring via US, β-hCG when appropriate size
  • Oocyte retrieval
  • Fertilisation (standard or ICSI)
  • Embryo transfer (transcervical at day 2-3 or 5)
• Poor response and cancelled cycle, excessive response and cancelled cycle (OHSS - 1-10%, fluid third-spacing, haemoconcentration, ascites, pleural effusion. MDM team, IV fluid and albumin replacement, thromboprophylaxis), bleeding/infection, miscarriage/ectopic, multiple pregnancy