Infertility & Semen Analysis

Question 1

When does NICE classify someone as infertile?

Answer 1

At 2 years without conceiving.

(But recommends investigating at 1 year)

Question 2

How many days abstinence should one have before semen analysis is done?

Answer 2

Minimum 3 days

Maximum 5 days.

Question 3

According to CG156 what is some advice you can give couples who are concerned about fertiliy?

Answer 3

1. Try to always see them together
2. 84% of couples using no contraception and having regular intercourse (Woman is <40yrs) will conceive in 1 year and 92% in 2 years.
3. Regular intercouse = every 2-3 days.
4. Reduce alcohol consumption
5. Stop smoking
6. Aim for healthy BMI (20-25)
7. Regular folic acid

Question 4

Which couples need further investigating according to NICE 2013, CG156?

Answer 4

1. A couple who have failed to conceive after 12m of regular unprotected intercourse should be offered investigation and referral.
2. Offer an earlier referral for:
   
   • women aged 36 or older.
   • Undergoing cancer treatment.
   • women who cannot have vagina intercourse.

Question 5

What are the Great Yarmouth and Waveney Clinical Commisioning Group criteria for Level 2 Fertility services?

Answer 5

1. Couples who are having regular unprotected sex for 12 months and have failed to conceive.
2. Have been in a stable relationship for more than 1 year.
3. Neither partner shoud have been undergone sterilisation or sterilisation reversal in the past.
4. Treatment may be denied on other medical grounds.

Question 6

According to Great Yarmouth and Waveney Clinical Comissioning Group, who should NOT be referred onto level 3 services? (IVF)

Answer 6

1. Women aged 42 years of over.
2. Couples with children from the current relationship (including adopted children).
3. Women with BMI <19 or >30.
4. Patients not registered with an East of England GP for at least 12 months.

Question 7

What are the causes of infertility?

Answer 7

1. Male factor (30%)
2. Unexplained (20%)
3. Ovulatory disorders (20%)
4. Tubal damage (15%)
5. Other (15%)

40% of couples will have both male and female factors.

Question 8

What are the 2 initial investigations that can be done at 1 year of being unsuccesful to get pregnant?

Answer 8

1. Semen anlaysis
2. Serum progesterone
   
   • if < 16 nmol/L - repeat and refer if consistently low.
   • 16-30nmol/l - repeat
   • >30nmol/l - indicates ovulation

Question 9

What are your values for Semen Analysis?

Answer 9

• Volume > or = 1.5ml
• pH > or =7.2
• Sperm concentration > or = 15 million per ml
• Total sperm number > or = 39 million per ejaculate
• Motility > or = 40% motile or > or =32% progressively motile.
• Vitality > or = 58% live
• Morphology > or =4% normal forms.

Question 10

What primary care investigations should be done for the female prior to referring couples to level 2?

Answer 10

Female

1. Day 1–5 FSH/LH to assess ovarian reserve and ovulation.
2. Day 21 (or 7d before period due) progesterone to assess ovarian reserve and ovulation.
3. Rubella status, chlamydia screening and an up to date smear are also required.
4. Serum Prolactin (if not ovulating)
5. If history of PID/ectopic/endometriosis, then hysterosalpingogram date for tubal patency.
6. HIV, Hep B and Hep C serology if referred for IVF (Stage 3)

Question 11

What primary care investigations should be done for the male prior to referring couples to level 2?

Answer 11

1. Semen analysis.
2. Testosterone level can also be helpful.

Question 12

How is a semen analysis collected and what are normal results?

• 3 days abstinence from intercourse
• Collection of specimen of semen in a sterile plastic container after masturbation
• Examine within 2 hours

Answer 12

Question 13

If a semen analysis is abnormal, how often should it be repeated?

Answer 13

In 3 months.

Sooner if grossly abnormal.

Question 14

Describe the WHO description of ovulatory disorders?

Answer 14

WHO 1: hypothalamic pituitary failure (low LH/FSH)

WHO 2: anovulatory infertility (e.g. PCOS)

WHO 3: Premature ovarian failure.

Question 15

What are some common causes of abnormal/absent sperm?

Answer 15

1. Idiopathic oligospermia - common.
2. Drug exposure - alcohol,smoking, drugs, exposure to industrial chemicals.
3. Varicocele (25% of infertile men)
4. Antisperm antibodies (5% of infertile men). Common after vasectomy reversal. Sperm clumped together.
5. Epididymitis, mumps,
6. Chromosomal abnormalities (Klinefelters syndrome XXY,
7. Congenitally absent vas (Cystic fibrosis)
8. Kallman’s syndrome (hypogonadotrophic hypogonadism)
9. Retrodgrade ejaculation (Post TURP, diabetes)
10. Hyperprolactinaemia

Question 16

What does azoospermia mean?

No sperm present in ejaculate. (8% on infertile men)

• *Obstructive Azoospermia**: Absent vas deferens) Normal-size testes, epididymal fullness, Normal FSH, Normal spermatogenesis in testicular biopsy
• *Non-Obstructive Azoospermia:** Small-soft testes, possible increased FSH. ~50% will have sperm in testes on extraction.

What Investigations should be done?

Answer 16

1. FSH, LH, Testosterone - hypogonadotrophic hypogonadism.
2. Prolactin to exclude hyperprolactinaemia
3. TSH - Thyroid function.
4. Transrectal ultrasound scan to look for absent Vas Deferens. (if absent test for CF)
5. Serum Karyotype (If genetic cause suspected.

If primary testicular failure will be given LH(HCG) and FSH for 6-12 months,

Question 17

What does oligospermia mean?

Answer 17

Low sperm concentration. (<15 million/mL)

Question 18

What does severe oligospermia mean?

Answer 18

<5 million/ mL

Question 19

What does Asthenospermia mean?

Answer 19

Absent or low motility sperm

Fewer than 50% spermatozoa with forward progression(categories a and b)or fewer than 25% spermatozoa with category a movement

Question 20

What does aspermia mean?

Answer 20

No ejaculate

Question 21

What does teratozoospermia mean?

Answer 21

Fewer than 30% spermatozoa with normal morphology.