Infertility Work-Up

Question 1

Define infertility. Differentiate between primary and secondary infertility.

Answer 1

Infertility: Failure to achieve pregnancy after 1 year of timed unprotected intercourse or donor insemination.

Primary infertility: Female partner has not had a prior pregnancy.

Secondary infertility: Female partner has had a prior pregnancy.

Question 2

What is the most common general cause of infertility, and what is the most common diagnosis within this category?

Answer 2

Ovulatory dysfunction

PCOS

Question 3

List five causes of hypogonadotropic hypogonadism.

Answer 3

Eating disorder
Extreme exercise
Stress
Hyperprolactinemia
Thyroid disease
CNS lesions
Kallman syndrome
Idiopathic

Question 4

What effects do fibroids & endometrial polyps have on fertility?

Answer 4

Fibroids - variable effect, probably dependent on location (submucosal fibroids most often associated with infertility)

Polyps - effects on fertility debated, but presence of polyps may be associated with decreased pregnancy rates following treatment for infertility

Question 5

What are the indications for infertility evaluation?

Answer 5

After 1 year unprotected intercourse if < 35
After 6 months unprotected intercourse if > 35
As soon as pregnancy desired if known problem or history of infertility for patient or partner

Question 6

List five tests that can be used to confirm ovulation.

Answer 6

Basal body temperature (ovulatory cycles associated with biphasic pattern) - not recommended
Progesterone > 3 ng/mL one week prior to expected menses
Midcycle LH surge (urinary or serum)
TV US (presumptive evidence: growth, then sudden collapse of follicle)
Endometrial biopsy (presence of secretory endometrium indicates presence of progesterone) - not recommended

Question 7

What is a clomiphene citrate challenge test, and what is its purpose?

Answer 7

Test of ovarian reserve
Give 100 mg CC daily CD5-9, measure FSH on CD3 & CD10, elevated FSH after CC treatment suggests diminished ovarian reserve

Question 8

Define asthenospermia.

Answer 8

Reduced sperm motility (< 40% motility)

Question 9

When working up male factor infertility, what are four key components of the groin exam?

Answer 9

Location of urethral meatus
Palpation & measurement of testes
Presence of vas deferens, epididymis
Presence or absence of varicocele

Question 10

On examining an infertile male patient, you note bilateral absence of the vas deferens. For what disease should you test the patient?

Answer 10

Cystic fibrosis

Question 11

What is the mechanism of elevated FSH in subfertile women?

Answer 11

Fewer follicles present, fewer recruited each month, decreased production of inhibin B by follicles, therefore decreased negative feedback on pituitary and consequently, elevated FSH

Question 12

What is the value of the antral follicle count & AMH in infertile women?

Answer 12

Tests of ovarian reserve
Predict response to ovarian stimulation during IVF
Do not predict pregnancy rates (therefore poor results do not preclude women from pursuing ART)