Management of Infertility

Question 1

What is the definition of infertility

Answer 1

Failure to conceive despite regular unprotected sexual intercourse over 12 months in absence of known reproductive pathology

Question 2

Why is infertility classed as a disease

Answer 2

It causes considerable psychological distress

Question 3

What are some factors that influence fertility

Answer 3

Female age
Duration of infertility
Previous pregnancy
Cause of infertility

Question 4

What are some reasons for the incidence of infertility increasing

Answer 4

Older women 
rise in increase in chlamydia infections 
increase in obesity 
increasing awareness of treatments 
change in expectations 
increasing male factor infertility

Question 5

What should be involved in the examination of a female in the infertility clinic

Answer 5

BMI
BP 
Urinalysis
General examination 
Pelvic examination

Question 6

What should be involved in the examination of a male in the infertility clinic

Answer 6

BMI
BP 
Urinalysis
General examination 
Urogenital examination

Question 7

What type of drug can cause an increase in prolactin

Answer 7

Antidepressents

Question 8

What types of drugs can cause a problem with Ovulation

Answer 8

NSAID

Question 9

What investigations are required for the female

Answer 9

Endocervical swab for chlamydia
Cervical smear if due
Blood for rubella immunity
Midluteal progesterone level

Question 10

What 3 things can Rubella syndrome cause to the newborn

Answer 10

Microcephaly (small head)
PDA (heart abnormalities)
Cataracts 
Rash at birth 
Low birth weight

Question 11

What type of vaccine is the Rubella vaccine

Answer 11

Live

Question 12

What is the treatment for chlamydia

Answer 12

Azithromycin tablet 1g

Question 13

What are some short-term affects of pelvic inflammatory disease

Answer 13

Tub-ovarian abscess
Peritonitis
Fitz-Hugh-Curtis Syndrome

Question 14

What are some long-term affects of pelvic inflammatory disease

Answer 14

Chronic pelvic pain
Infertility
Ectopic pregnancy

Question 15

What is the treatment for an ovarian abscess

Answer 15

Surgically drain the abscess and prescribe broad spectrum Antibiotics for 2 weeks

Question 16

What is a strong suggestion of ovulation

Answer 16

Regular menstruation

Question 17

What can we measure to confirm ovulation in someone with regular cycles

Answer 17

Midluteal serum progesteron

Question 18

What are the 3 groups of ovulatory disorders

Answer 18

Group 1 - Hypothalamic
Group 2 - Hypothalamic Pituitary dysfunction
Group 3 - Ovarian Failure

Question 19

What are some of the causes of Hypothalamic ovulatory disorders

Answer 19

Stress 
Excessive exercise 
Anorexia
Kallman's syndrome 
Isolated gonadotrophin deficiency

Question 20

What is the most common type of ovulatory disorders

Answer 20

Hypothalamic pituitary dysfunction including PCOS

Question 21

What are some symptoms of PCOS

Answer 21

Hirsutism
Acne/ oily skin
Increase in testosterone levels 
Oligomennorhoea
Central obesity

Question 22

What is seen on US to confirm Polycystic ovary

Answer 22

More than 12 follicles between 2-8 mm in diameter in a single plane

Question 23

Patients must have 2 of what to make a diagnosis of PCOS

Answer 23

Irregular menstrual cycle, hirsuitism, acne, sub fertility, alopecia, obesity 
Biochemical- in days 2-5
Elevated serum LH 
LH/FSH >2 
Normal estradiol
Low progesterone
Normal or mildly elevated prolactin
Raised testosterone

Question 24

What are the first line drugs used to induce ovulation

Answer 24

Antioestrogens e.g. Clomifene citrate or tamoxifen

Aromatase inhibitors e.g. Letrozole

Question 25

How should Clomifene citrate be taken

Answer 25

Day 2-6 of cycle (1 tablet for 5 days)

Question 26

What is the advantage of using Tamoxifen to Clomifene citrate

Answer 26

The oestrogen effect on endometrium

Question 27

How do Aromatase inhibitors work

Answer 27

They inhibits ovarian aromatase enzyme

Question 28

What are some second line treatments for inducing ovulation

Answer 28

``` Clomifene citrate + metformin (to improve sensitivity) Gonadotrophin therapy (daily injections) Laparoscopic ovarian diathermy ```

Question 29

What do we look for when examining sperm

Answer 29

Volume >1.5ml count >15x 10^6/ml Progressive motility and >4% normal morphology

Question 30

What is the most common cause of male infertility

Answer 30

Idiopathic

Question 31

What are some obstructive causes of male infertility

Answer 31

Vasectomy Infection Congenital absence of vas deferens (Cystic Fibrosis)

Question 32

What are some of the non-obstructive causes of male infertility

Answer 32

Undescended testis Orchitis Torsion/trauma Chromosomal (Kleinfelter's syndrome 47XXY)

Question 33

What are some other causes of male infertility

Answer 33

Hormone - hypothyroidism, hypogonadism, hypogonadotrophic, testicular cancer Chemo, radio, erectile dysfunction, immunological

Question 34

What are the treatment options for male infertility

Answer 34

Surgery to obstructed vas deferins Intrauterine insemination Intracytoplasmic sperm injection (ICSI) Donor insemination

Question 35

What are the most common causes of tubal disease

Answer 35

Infective: | Pelvic inflammatory disease inc. chlamydia or gonorrhoea

Question 36

What are some non-infective causes of the tubal disease

Answer 36

``` Endometriosis Surgical Fibriods Polyps Congenital ```

Question 37

What are the treatment options for tubal disease

Answer 37

``` Tubal surgery (reversal of sterilisation) IVF ```

Question 38

How are eggs collected for IVF treatment

Answer 38

Ultrasound guided

Question 39

How big is a blastocyst and at what stage does this form

Answer 39

More than 125 cells - blastocyst

Question 40

What are some general factors for improving the likelihood of pregnancy

Answer 40

``` Sex 2-3 times per week Low alcohol intake Between 19-29 BMI No smoking Folic acid Rubella immunity Cervical smears up to date ```