Infertility/fertility

Question 1

Primary vs secondary infertility

Answer 1

Primary - couple never been able to conceive
Secondary - couple cannot get pregnant again, previously could w/o difficulty

Question 2

What are the general causes of intertility?

Answer 2

• Male infertility - 30%
• Ovulatory disorders - 25%
• Tubal damage - 20%
• Uterine or peritoneal disorders - 10%
• No identifiable cause

Question 3

What is general advice to couples trying to conceive?

Answer 3

• Sexual intercourse every 2-3 days throughout womens cycle
• Prep for pregnanct eg. preconceptual folic acid
• Smoking cessation for both parties
• Avoid drinking excessive alcohol
• Women aim for BMI 19-25

Question 4

What factors affect natural fertility?

Answer 4

• Increasing age
• Obesity
• Smoking
• Tight fitting underwear - maes
• Excessive alcohol consumption
• Ilicit drug use

Question 5

What are some ovulation/endocrine disorders causing infertility?

Answer 5

• PCOS
• Pit tumour
• Sheehan’s syndrome
• Hyperprolactinaemia
• Cushing’s
• Premature ovarian failure

Question 6

What are some of the tubal and uterine abnormalities causing infertility?

Answer 6

Tubal - congenital anatomical abnormalities and adhesions following PID
Uterine - bicornate uterus, fibroids, adhesions of the uterus

Question 7

What are the ix into infertility carried out in primary care?

Answer 7

• BMI, low = anovulation, high = PCOS
• Chlamydia screen
• Semen analysis
• Female hormonal testing
• Rubella immunity

Question 8

What is involved in female hormonal testings?

Answer 8

• Serum LH and FSH day 2 to 5 of cycle
• Serum progesterone on day 21 or 7 days before end
• Anti Mullerian hormone
• TFTs
• Prolactin when sx of amenorrheoa and galactorrhea

Question 9

How are female hormonal tests interpretted?

Answer 9

• High FSH = poor ovarian reserve, pit gland producing extra FSH to attempt to stim follicular development
• High LH = PCOS
• Rise of progesterone on day 21 = ovulation occurred and corpus luteum formed and secreting progesterone
• Anti Mullerian hormone - marker of ovarian reserve, high = good

Question 10

What ix into infertility are carried out in secondary care?

Answer 10

• US pelvis, look for polycystic ovaries or structural abnormalities of uterus
• Hysterosalpingogram
• Laparoscopy and dye - patency of fallopian tubes, adhesions, endometriosis

Question 11

What is a hysterosalpingogram?

Answer 11

Scan to assess shape of the uterus and patency of the fallopian tubes.
Tubal cannulation under XR guidance can be performed during the scan to open tubes = increase rate of conception.
Contrast into uterine cavity and fallopian tubes. Risk of infection - prophylactic abx and screen for STI.

Question 12

What is the management of anovulation?

Answer 12

• Weight loss if overweight pt w PCOS
• Clomifene and letrozole stim ovulation
• Gonadotropins stim ovulation if resistant to clomifene
• Ovarian drilling (punctures holes in ovaries using diamthermy or laser = improve hormones = ovulation)
• Metformin

Question 13

What is clomifene?

Answer 13

Anti oestrogen - selective oestrogen receptor modulator. Give on day 2 to 6. Stops neg feedback of oestrogen on hypothalamus = increase GnRH = increase FSH and LH.

Question 14

What is the management of tubal factors that cause infertility?

Answer 14

• Tubal cannulation during hysterosalpingogram
• Laparoscopy to remove adhesions or endometriosis
• IVF

Question 15

What is the advice for men providing a semen sample?

Answer 15

• Abstain from ejaculation for at least 3 days
• Avoid hot baths, sauna and tight underwear
• Attempt to catch the full sample
• Deliver the sample to the lab w/i 1 hour of ejaculation
• Keep the sample warm

Question 16

What are some abnormal sperm results?

Answer 16

Polyspermia - high number of sperm in semen sample = >250 million/ml
Oligospermia - reduced number, mild = 10-15 mil/ml, mod = 5-10mil/ml, severe = <5mil/ml
Cryptozoospermia - <1mil sperm/ml
Azoospermia - no sperm in the semen

Question 17

What are normal sperm results?

Answer 17

Normospermia:
- >1.5ml of semen
- pH >7.2
- Conc >15mil/ml
- Total number = >39 mil per sample
- >40% mobile and >58% active

Question 18

What are some pre testicular causes of infertility?

Answer 18

Hypogonadotrophic hypogonadism = reduced testosterone which is necessary for sperm:
- Pathology of pit gland or hypothalamus
- Suppression due to stress, chronic conditions or hyperprolactinaemia
- Kallman syndrome - delayed or absent puberty and impaired sense of smell

Question 19

What are the testicular causes of infertility?

Answer 19

Acquired damage - mumps, trauma, RT and chemo, cancer, cryptochidism
Genetic or congenital disorders - Klinefelter syndrome, Y chromosome deletions, Sertoli cell only sydrome, anorchia

Question 20

What are some post testicular causes of infertility?

Answer 20

• Ejaculatory duct obstruction
• Retrograde ejaculation
• Scarring from epididymitis eg. chlamydia
• Absence of vas deferens
• Damage - trauma, surgery, cancer

Question 21

How do you investigate abnormal semen analysis?

Answer 21

• Hormonal analysis w LH, FSH and testosterone
• Genetic testing
• Further imaging eg. transrectal US or MRI
• Vasography - inject contrast into vas deferens
• Testicular biopsy

Question 22

What is the management of male factor infertility?

Answer 22

• Surgical sperm retrieval if obstruction
• Surgical correction of obstruction
• Intra uterine insemination
• Intracytoplasmic sperm injection - sperm directly into cytoplasm of egg
• Donor insemination

Question 23

What is involved during one cycle of IVF?

Answer 23

• Suppress natural menstrual cycle
• Ovarian stim
• Oocyte collection
• Insemination/intracytoplasmic sperm injection
• Embryo culture and then transfer

Question 24

How is the natural menstrual cycle suppressed?

Answer 24

• GnRH agonist protocol - injection during luteal phase, 7 days before expected onset of period, stim pit gland to secrete FSH and LH, negative feedback on hypothalamus due to surge = reduction in natural GnRH = suppress menstrual cycle
• GnRH antagonist protocol - daily SC injectoin eg. cetrorelix, from day 5-6 of ovarian stim. Suppresses LH so no ovulation.

(want follicles to be made but not released as want to collect them)

Question 25

How is ovarian stim carried out?

Answer 25

Meds to develop multiple follicles in ovaries -SC FSH at day 2 for ~2 weeks. Transvaginal USS to monitor follicles.
When enough follicles have developed FSH stopped and hCG injection 36 hours before egg collection = stim final maturation of follicle ready for collection.

Question 26

What is involved in oocyte collection and insemination?

Answer 26

Oocytes collected under US guidance, aspirate fluid from each follicle = mature oocytes in it. Check fluid to see if have any oocytes. Male produces a semen sample or frozen samples can be made - sperm and egg mix and egg is hopefully fertilised.
May need to do ICSI in male factor infertility if reduced no or quality of sperm, isolate highest quality sperm and directly inject into egg.

Question 27

What is involved in embryo culture and transfer?

Answer 27

Fertilised eggs incubated for 2-5 days to see if any develop or grow, monitored until they reach blastocyst stage.
Highest quality embryos are selected for transfer. Catheter through cervix into uterus, single embryo transferred. Remaining embryos frozen.

Question 28

What is ovarian hyperstim syndrome?

Answer 28

Complication of ovarian stim in IVF treatment - associated w hCG use to mature follicles.

Question 29

What are the features of OHSS?

Answer 29

• Early presents w/i 7 days of hCG injection, late is >10 days after
• Abdo pain and bloating, N+V
• Diarrhoea
• Hypotension and hypovolaemia
• Ascites
• Pleural effusions
• Renal failure
• Peritonitis from rupturing follicles releasing blood
• Prothrombotic state - risk VTE

Question 30

What is the management of OHSS?

Answer 30

• Oral fluids
• Monitor urine output
• LMWH - prevent VTE
• Paracentesis to remove ascitic fluid if needed
• IV colloids