Subfertility

Question 1

How is sub-fertility defined?

Answer 1

Woman of reproductive age who has not conceived after 1y of regular, unprotected sexual intercourse

Question 2

Recall the groups of ovulatory disorders that may contribute to sub-fertility

Answer 2

Group 1: hypothalamic-pituitary failure (hypogonadotrophic hypogonadism, low weight/ excess exercise, Kallman’s, Sheehan’s)

Group 2: Hypothalamic-pituitary-ovarian dysfunction (PCOS, hyperprolactinaemia)

Group 3: Ovarian failure (POI)

Question 3

What hormone levels are seen in each type of ovulatory disorder?

Answer 3

Hypothalamic-pituitary failure: Low LH, low FSH, low oestrogen

Hypothalamic-pituitary-ovarian dysfunction: normal LH + FSH + oestrogen

Ovarian failure: high LH + FSH, low oestrogen

Question 4

Other than ovulatory disorders, what can cause sub-fertility in the female?

Answer 4

Tubal disorders

Cervical/ uterine (eg fibroids)

Genetic/ developmental (Turner’s/ CF)

Lifestyle/ functional (smoking, method of sex)

Question 5

Recall 3 structural causes of infertility in men

Answer 5

Cryptochordism
CF- absence of vas deferens
Varicocele

Question 6

Give 1 genetic cause of infertility in men

Answer 6

Klinefelter’s XXY

Question 7

Give 2 infectious causes of infertility in men

Answer 7

Epididymitis
Mumps orchitis

Question 8

How should a semen sample be collected?

Answer 8

Analysis should be performed after min 2 days + max 7 days abstinence.
Sample needs to be delivered to the lab within 1h

Question 9

What should be included in the history when investigating sub-fertility?

Answer 9

Duration and type of infertility
Coital frequency
Menstrual hx
PCOS Sx
Contraceptive hx
Previous STI
PSHx
DHx
SHx (EtOH + smoking)

Question 10

What should be looked for on examination in a female with sub-fertility?

Answer 10

BMI, Hirsuitism, Acne (PCOS)
Galactorrhoea (hyperprolactinaemia)
Syndromic features (Turners)

PV: Vaginismus (sexual difficulty)

Bimanua: cervical motion tenderness (PID), abdo mass (Fibroids)

Question 11

What are the first-line basic tests to do in men and women to investigate sub-fertility?

Answer 11

Men: semen analysis (2 tests, 3m apart) + chlamydia screen

Women:
Day 21 progesterone (>30 indicates ovulation has occurred)
Chlamydia screen
FSH, LH, Oestradiol
Ovarian reserve tests

If irregular menstrual cycle: Prolactin, TFTs, testosterone

Question 12

What are the Ovarian Reserve Tests?

Answer 12

FSH at Day 3 (to find basal level)
Anti-Mullerian hormone (AMH)
Antral follicle count (using TVUSS)

Question 13

When is a tubal assessment performed? How?

Answer 13

After referral to secondary care

If no other comorbidities: hysterosalpingography (HSG) to assess patency

If comorbidities (eg hx of PID/ ectopics/ endometriosis) → laparoscopy + dye

Question 14

What is the initial management for sub fertility?

Answer 14

Treat underlying cause e.g Weight loss for overweight PCOS

Sex every 2-3d

Folic acid

Smoking cessation + reduce EtOH

Healthy BMI 19-25

Question 15

When should investigations be performed for sub-fertility?

Answer 15

Start Ix if not conceived after 1 y of regular (every 2–3 d) UPSI

Offer Ix earlier than 1y if identified as less likely to conceive

Question 16

When should referral be made for sub-fertility? (Give 4 examples)

Answer 16

If Ix normal + no conception after 1y of UPSI

> 36y

Oligoamennhorea/ amennhorea

Prior Tx for cancer

Question 17

What is the medical management for Group 1 (hypothalamic/ pituitary) sub-fertility?

Answer 17

Reverse cause e.g. gain weight, reduce exercise

Pulsatile GnRH/ directly replace gonadotropins

Question 18

What is the medical management for Group 2 (HPO dysfunction) sub-fertility?

Answer 18

Weight loss + metformin

Clomifene to induce ovulation (SERM → increased GnRH release- if fails can try gonadotropins)

Dopamine agonists for hyperprolactinaemia

Question 19

How can anovulation be managed in PCOS?

Answer 19

Ovulation induction:
1st line: clompihene (blocks oestrogen receptor to increase LH/FSH release)

2nd line: FSH/LH injections

3rd line: Pulsatille GnRH or DA agonists

Question 20

Which causes of sub-fertility can be managed surgically?

Answer 20

Proximal tubal obstruction: Tubal microsurgery (catheterisation or cannulation)

PCOS: Laparoscopic ovarian drilling

Endometriosis: surgical ablation/ resection + laparoscopic adhesiolysis

Fibroids: Myomectomy

Obstructive azoospermia: surgical correction of epididymal blockage to restore patency

Question 21

When can surgical correction not be used for male infertility?

Answer 21

In CF
“can’t repair what wasn’t there”

Question 22

Recall the 5 options for assisted conception

Answer 22

Intrauterine insemination +/- LH/FSH
IVF
Intracytoplasmic sperm injection
Donor insemination +/- LH/FSH
Donor egg with IVF

Question 23

How is IVF performed?

Answer 23

Leave egg + sperm in a petri dish + they fertilise each other

Question 24

What is NICE guidance for availability of IVF?

Answer 24

Women <40 offered 3 cycles of IVF if
1. Subfertile for 2y
2. Not pregnant after 12 cycles of artificial/ intrauterine insemination

Women 40-42 offered 1 cycle of IVF if:
1. subfertile for 2y +/- after 12 cycles of AI
2. never had IVF
3. No evidence of low ovarian reserve
4. Informed about additional implications of IVF at this age

Question 25

What are 3 indications for intracytoplasmic sperm injection?

Answer 25

Oligospermia
Poor fertilisation (DM, erectile dysfunction)

Question 26

How is ICSI carried out?

Answer 26

Sperm directly injected into egg

Question 27

What are 4 indications for donor egg with IVF treatment?

Answer 27

POI
BL oophrectomy
Gonadal dysgenesis
High-risk genetic disorder

Question 28

What is intrauterine insemination?

Answer 28

Sperm injected through catheter into uterus

Question 29

What should be looked for on examination in a male with sub-fertility?

Answer 29

BMI, secondary sexual characteristics/ gynaecomastia (hypogonadism)

Penis: position of urethral meatus (structural abnormality)

Scrotal exam: lumps (Ca, varicocele, hernia), small + soft (hypogonadism), undescended