L10 - Infertility

Question 1

OVERVIEW OF INFERTILITY

i) what % of couples does it affect?
ii) when do you get offered help according to NICE guidelines?
iii) what % of couples concieve after one year
iv) after how many failed cycles of artificial insemnation should further assesment be undertaken?
v) name three situations where a women would be referred for early specialist consultation

Answer 1

i) 15%
ii) if a woman hasnt conceived after a year offer investigation along with partner
iii) 84% couples concieve after one year
iv) 6 failed cycles warrants further assess

v) specialist consulation for
- women >36yrs
- known cause of infertiluty of hx of predisposing factors
- investigations show no change of pregancy with expectant mx

Question 2

CAUSES OF INFERTILITY - FEMALE FACTORS

i) what % are due to female factors? what % are unexplained?
ii) what % of infertility does PCOS account for?
iii) name three other ovulation disorders that can cause infertility
iv) name two things that can cause tubal blockage
v) name two uterine problems that may contribute

Answer 2

i) 30% female factors and 25% unexplained
ii) PCOS accounts for 80%
iii) premat ovarian failure, hypopituitarism (low FSH and LH), RT/chemo
iv) endometriosis and pelvic inflamm disease
v) polyps, fibroids and synehciae (adhesions in uterine cav)

Question 3

INFERTILITY WORK UP

i) which four hormones should be tested on day 2 or 3 of cycle?
ii) what phase should progesterone be measured in? what does this test?
iii) name two diseases that are screened for
iv) what does a HSG scan test for? what other test may be used?
v) what does a pelvic ultrasound test for? (2)
vi) what is the biggest factor affecting fertility potential?

Answer 3

i) FSH, LH, oestradiol and prolactin

ii) mid luteal phase (usually day 21 if reg cycle)
- tests for ovulation

iii) screen for chlamidya and rubella

iv) HSG allows visualisation of tubes - look for tubal blockage
- HyCoSy (US and dye) non invasive look at tubal damage

v) pelvic US for fibroids or polyps
vi) age

Question 4

OVARIAN RESERVE

i) which pituitary hormone is used to test ovarian reserve? how do levels correlate to ovarian reserve?
ii) what imaging is used to look at antral follicle count (ovarian reserve)?
iii) which hormone is high when there is high ovarian reserve? why is this a good predictor of OR?
iv) what day is best to do an ovarian reserve assessment? name four hormones to be checked

Answer 4

i) FSH - high FSH = low ovarian reserve
ii) use pelvic ultrasound to look at follicles
iii) AMH is high when high ovarian reserve due to it being released directly from follicles
iv) day 2-3 - FSH, LH, oestradiol and AMH

Question 5

ANTI MULLERIAN HORMONE

i) which cells produce it? where are they found?
ii) are levels constantly or varied through the month? how do they change with age?
iii) which two antral stages is there high AMH production?

Answer 5

i) granulosa cells in the ovary
ii) levels are constant through the month but decline with age
iii) high prod in pre antral and small antral stages

Question 6

NICE GUIDELINES - OVERVIEW

i) what is advised to check ovarian reserve?
ii) is internuterine insemnation commonly used? who is it reserved for (2)
iii) what is the lower and upper age for fertility tx?
iv) would IUI be offered for unexplained fertility?
v) after how many years of trying would women be offered IVF if they have unexplained infertility?

Answer 6

i) AMH not FSH

ii) no
- used for people that cant or dont have heterosexual intercourse

iii) no lower limit (18yrs) and 42 is upper age limit
iv) no - no benefit over normal intercourse
v) after 2 years

Question 7

NICE GUIDELINES - FERTILITY TX

i) how many rounds of IVF can be offered to women under 40?
ii) how many cycles may be offered to women 40-42yrs? what two conditions need to be met to have this?
iii) which drug can be used for ovulation induction? what hormone is given alongside it? does this increase risk of cancer?
iv) is IVF more effective in women who have achieved birth before?

Answer 7

i) three full cycles

ii) one full cycle
- never had IVF before and no evidence of low avarian reserve

iii) clomid can induce ovulation + FSH injections
- does not increase risk of cancer

iv) yes

Question 8

METFORMIN AND PCOS

i) which two things do women may women with PCOS have?
ii) how does metformin affect insulin sensitivity? what is a side effect?
iii) were differences in ovulation rates seen between metformin and placebo group?
iv) which other drug has shown to have the highest live birth rate? is there benefit if adding metformin?

Answer 8

i) insulin resistance and high androgens

ii) metformin improves insulin sensitivity
- side effect = nausea and vomiting and diarrhoea

iii) no difference in ovulation rates

iv) clomiphene has highest live birth rate
- no benefit of adding metformin

Question 9

IVF

i) which women may this be useful in?
ii) which two hormones do buserelin injections decrease?
iii) injection of which hormone is given to stimulate the ovaries?
iv) which day is HCG injection given? what happens after this
v) name two ways sperm can be retrieved if there is little or no sperm in ejaculate?

Answer 9

i) women with tubular blockage
ii) buserelin works on the pit gland to reduce LH and FSH
iii) FSH injections stimulate the ovaries
iv) HCG on day 12 then eggs are collected
v) intra cytoplasmic sperm injection or surgical sperm retrieval

Question 10

IVF EMBRYO TRANSFER

i) at what day is the embryo implanted? what is it called at this stage?
ii) where is the embryo injected into? what is used to guide this
iii) what is the overall pregnancy rate for women <36 yrs?
iv) what is the overall pregnancy rate?

Answer 10

i) day 5 = blastocyst
ii) injected into the uterus under US guidance
iii) 60%
iv) 54%