Subfertility

Question 1

What is secondary sub fertility?

Answer 1

Inability to become pregnant or to carry a baby to term after previously giving birth

Question 2

Conception rates in couples having regular sex

Answer 2

After 1 year - 84%

After 2 years - 92%

Question 3

Causes of subfertility

Answer 3

Anovulation - 21%
Male factor - 25%
Tubal factor - 15-20%
Unexplained - 28%
Endometriosis - 6-8%

Women (67%)

Question 4

Causes of of anovulation

Answer 4

Premature ovarian failure 
Turner’s syndrome
Surgery/chemotherapy 
PCOS (80%)
Kallman’s syndrome (hypogonadotrophic hypogonadism)
Hyperprolactinaemia

Question 5

Investigations in primary care

Answer 5

Chlamydia screen
Baseline hormone profile (Day 2-5 FSH [should be >10] and LH)
TSH, prolactin, testosterone and rubella status
Mid literal progesterone level (>30 for ovulation)
Semen analysis (selenium, zinc and vitamin c)

Question 6

Lifestyle modification

Answer 6

Healthy diet
Stop smoking and/or recreational drugs
Reduce alcohol consumption to less that recommended limits
Regular exercise
Regular intercourse
(Folic acid)

Question 7

Methods of ovulation induction

Answer 7

Weight loss or gain 
Clomifene citrate (anti-oestrogen)
Laparoscopic ovarian drilling (only for PCOS)
Gonadotrophins
Metformin

Question 8

Normal semen analysis

Answer 8

Volume >1.5mls
Concentration > 15x10ml
Progressive motility >32%
Total motility >40%
Normal forms >4%

Question 9

Factors to consider when trying to conceive

Answer 9

Female age
Uterine function
Duration of trying 
Lifestyle factors
Medical history
Previous pregnancy

Question 10

Hallmarks of PCOS

Answer 10

Elevated LH
Insulin resistance

Leading to:

• ovarian growth
• ovarian cyst formation
• androgen production

Question 11

Symotoms of PCOS

Answer 11

Androgen excess - hirsuitism, acne
Obesity
Irregular menses
Amenorrhea

Question 12

Diagnosing PCOS

Answer 12

Serum testosterone

LH (will be increased)
FSH (will be decreased) ratio LH:FSH can be 3:1

Prolactin, TSH
Pelvic USS - enlarged follicles (>10mm)

Question 13

Criteria for definitive diagnosis of PCOS

Answer 13

2 of the following 3 criteria

i) irregular menses
ii) evidence of androgen excess hirsuitism,acne
iii) polycystic ovaries (>10 per ovary)

Question 14

Treatment for PCOS

Answer 14

Oral contraceptive - suppress androgens - decreases testosterone and LH
Weight loss

If pregnancy desired:
Metformin
Clomiphene

Question 15

Factors that affect tubal function

Answer 15

Pelvic surgery
Infection: chlamydia, gonorrhea, PID
Endometriosis

Question 16

Possible causes of unexplained subfertility

Answer 16

Subtle abnormalities with oocyte and/or sperm function
Defective endometrial receptivity 
Subclinical endometriosis
Nutritional factors
Undiagnosed or untreated coeliac disease
Immunological factors

Question 17

What is IUI?

Answer 17

Intrauterine insemination

Useful in male subfertility, unexplained subfertility and same sex couples

Question 18

What is ICSI?

Answer 18

Intracytoplasmic sperm injection

Question 19

What is premature ovarian failure?

Answer 19

Loss of function of the ovaries before the age of 40