L7 - Infertility

Question 1

What are the requirements for conception?

Answer 1

• Motile sperm able to reach and fertilise egg
• Timely release of competent oocyte
• free passage for sperm
• A mature endometrium that allows implantation

Question 2

Define infertility?

Answer 2

Inability to conceive after 2 year of frequent unprotected intercourse

Question 3

What causes infertility?

Answer 3

unexplained, ovulatory, male factors, tubal, endometriosis

Question 4

What are the indications for early investigations?

Answer 4

Female:
Aged over 35 years
Amenorrhoea/oligomenorrhoea
Previous abdominal/pelvic surgery
Previous PID/STD 
Abnormal pelvic examination

Male:
Previous genital pathology (history of testicular maldescent, surgery, infection or trauma, there is a greater incidence of abnormal semen parameters)
Previous STD
Significant systemic illness
Abnormal genital examination

Question 5

What may be the reason for abnormal sperm analysis?

Answer 5

No reason in 50%

1ry testicular failure is the commonest cause for oligo/azoospermia

Obstructive or non-obstructive azoospermia  FSH, LH & T

Y chromosome microdeletion & cystic fibrosis if sperm count < 5 million

Question 6

How would you assess a female?

Answer 6

Screen for chlamydia and rubella.
ovarian reserve - check FSH/LH/E2 (early follicular phase hormone level)
check AMH (Anti-mullarian hormone) and AFC (antral follicle count)
Tubal test

Question 7

What is AMH - anti mullarian hormone ?

Answer 7

hormone produced by the granulosa cells of pre-antral and small antral stages
declines with age but steady throughout monthly periods
higher = good response

Question 8

When do the follicles undergo atresia?

Answer 8

1 - at premordial stage

2 - At antral stages upon FSH deprivation

Question 9

Describe tubal patency

Answer 9

Unblocked tubes
if blocked = disease
Can be proximal 25% or distal 75% - in the fimbrial end.

Question 10

What is the commonest cause of tubal damage?

Answer 10

PID secondary to chlamydia

Question 11

What are other causes of tubal damage?

Answer 11

septic abortion
ruptured appendix
pelvic surgery
ectopic pregnancy

Question 12

How can you check for tubal damage?

Answer 12

Hysterosalpingogram (HSG)
Hysterosalpingo-contrast-ultrasonography (HyCoSy)
Laparascopy and dye
Chlamydia screening before instrumentation

Question 13

HSG

Answer 13

Done 2-5 days after menstruation

If have history of PID, give antibiotics to prevent flare up

Question 14

What are the advantages of HSG?

Answer 14

relatively safe
easy to do
delineation of the of the uterine cavity and fallopian tubes

Question 15

What are the disadvantages of HSG?

Answer 15

Inability to assess the pelvic peritoneum

Question 16

Lap and Dye

Answer 16

invasive with risk of visceral injury to patient
more sensitive and specific
chance to diagnose and treat endometriosis and adhesions

Question 17

Uterine abnormality

Answer 17

Adhesions, polyps, submucous fibroids and septae,

Hysteroscopy is better than HSG and TVS at detecting the abnormalities

Question 18

Ovulation induction

Answer 18

Clomid (clomifene citrate) for women who have PCO
anti-oestrogen effect on HPA 
FSH injections for resistant PCO 
risk of multiple pregnancy 
monitor first cycle using uss

Question 19

What are the indications for IUI treatment?

Answer 19

mild male factor

mild endometriosis

Question 20

What are the benefits of IUI treatment?

Answer 20

Less stress
Less invasive
Less tech
Cheap

Question 21

When would you do IVF?

Answer 21

Tubal damage

Low sperm quality

Unexplained infertility

Low ovarian reserve