Subfertility

Question 1

Definition of subfertility

Answer 1

The Failure to conceive after 1 year of regular unprotected intercourse

Question 2

Incidence of subfertility

Answer 2

1 in 6/7 couples

84% of couples will conceive within 1yr of regular sex and 94% within 2yrs.

Question 3

Effects of personal factors on chance of conception

Answer 3

Prior pregnancy - 1.8x
<30yrs - 1.5x
Male or tubal defect - 0.5x
Endometriosis - 0.4x

Question 4

Causes of Subfertility

Answer 4

Male factor
Anovulation
Tubal factors
Other hormonal factors

Question 5

Causes of Anovulation

Answer 5

Hypothalamic or Pituitary dysfunction (high prolactin)
Thyroid dysfunction (low T3)
Ovarian Failure 
PCOS (high LH and testosterone)

Question 6

PCOS

Answer 6

A tonic elevation of LH and mildy high testosterone

treat with clomiphene, nuserelin+hMG, ovarian diathermy or drilling

Question 7

Ovarian Failure

Answer 7

hyper- or hypo- gonadotrophic hypogonadism - depending on if there is high or low FSH/LH
if necessary treat with ovum donation

Question 8

Tubal Factors

Answer 8

Can be due to Infection (PID or STI), surgery, ectopics or endometriosis
Inspect with a hysterosalpingogram

Question 9

Investigating the Male Factor

Answer 9

Measure sperm count - if normal wait and investigate the women
If low measure FSH - if normal check for obstruction, if high indicates testicular failure

Question 10

Causes of male subfertility (6)

Answer 10

Infections (mumps or STIs) Congenital problems
Trauma Varicocele
Radiotherapy Drugs

Question 11

Semen analysis

Answer 11

2-5ml of semen which should have a sperm density of >15x10^6/ml
40% or more should be progressively motile, with 32% being rapidly progressive
At least 4% should be morphologically normal

Question 12

Ratio of infertility categories

Answer 12

1/3 each male, female and combined

Question 13

Male sterilisation

Answer 13

simple OP under LA/GA which works after a couple of hours, x2 semen analysis before UPSI (16 & 20wks). 5-30% will have complications (chronic testicular pain, bruising, sperm granuloma, infection, haematoma)
Failure rate is 1/2000 and reversal is 55% 10yrs.

Question 14

Female Sterilisation

Answer 14

Day case Laparoscopy under GA, increased risk of ectopic if fails (1/200).
Rate of successful reversal is 50-60%

Question 15

Ovarian hyperstimulation syndrome

Answer 15

a potentially fatal complication of 33% of IVF where >20 follicles grow leading to very high eostrogen.

Question 16

Mild OHS

Answer 16

bloating, abdo pain and ovaries <8cm

Question 17

Moderate OHS

Answer 17

Moderate abdo pain, N&V, USS ascities, ovaries 8-12cm

Question 18

Severe OHS

Answer 18

clinical ascities, oligouria, ovaries >12cm, increased haematocrit and serum protein

Question 19

Critical OHS

Answer 19

tense ascities or hydrothorax,

Haematocrit >55%, raised WCC, anuria, thromboembolisms and ARDS

Question 20

Risk factors for OHS

Answer 20

Women with PCOS are at increased risk

Younger women and those with high eostrogens or more follicles. BhCG or GnRH supplementation

Question 21

Basic investigations of infertility

Answer 21

Semen analysis (>15m/ml, >50% motile, >4% morphology normal, >1-6.5ml)
Serum progesterone 7 days before period. (30 indicates ovulation)

Question 22

Advice for couples trying to conceive

Answer 22

Folic acid
Aim for BMI 20-25
Advise for regular sexual intercourse every 2-3days
Smoking and drinking advice.

Question 23

Forms of Male infertility

Answer 23

Few sperm (oligozoospermia)
No sperm (azoospermia)
No semen (Aspermia)
Little semen (hypospermia)
Low motility (Asthenozoospermia)
Deformed sperm (Teratozoospermia)
Leucospermia (WBCs in the semen, can indicate infection)
Necrozoospermia (all sperm are dead)

Question 24

Development of Sperm

Answer 24

Spermatagonia (46x1) replicate by mitosis and one daughter cell replicates chrs to become a primary spermatocyte (46x2) which then divides into 2nary spermatocytes (23x2) which divide into spermatids (23x1) which mature into spermatazoa

Question 25

Development of Eggs

Answer 25

Oogonia replicate into a primary Oocytes (46x2) which divide into a 2nary Oocyte (23x2) and a polar body. 2nary Oocytes (23x2) excrete another polar body to become an egg (23x1)

Question 26

Female sterilisation

Answer 26

A in hospital operative procedure which is 99% effective in the first yr, reducing slightly after that. Increased risk of ectopic (15-20%) if fails. Used by 1/3 of married women making it the most common method. Do not need partners consent

Question 27

Clomifene citrate

Answer 27

A SERM which is used to induce ovulation and is used in cases of anovulatory subfertility. Has also been used off-licence in treatment of 2nary male hypogonadism. It is also used as a form of performance enhancer for male atheletes.