Subfertility

Question 1

What is sub fertility?

Answer 1

Failure to concieve after 12 months of regular unprotected sex

Question 2

How many people are affected by sub fertility?

Answer 2

1 in 7 couples

Question 3

What is the chance of a healthy couple conceiving within a single menstrual cycle?

Answer 3

20%

Question 4

What are important factors for fertility?

• main factor
• modifiable factors

Answer 4

Female age

Also: smoking, stress, BMI extremes

Question 5

What age does fertility drop off sharply for women?

Answer 5

36

Question 6

What age does fertility drop off sharply for men?

Answer 6

50

Question 7

How long does sperm survive for in the reproductive tract?

Answer 7

Up to 72 hours

Question 8

What medication must women commence immediately if they are planning on getting pregnant?

Answer 8

Folic acid

Question 9

What are categories of problems that could cause subfertilitY?

Answer 9

Ovarian
Tubal
Uterine / endometrial
General medical conditions

Question 10

What is the most common ovarian cause of sub fertility?

Answer 10

PCOS (due to oligomenorrhoea)
Hypothalamic hypogonadism
Pituitary disease

Question 11

What are tubal problems that cause sub fertility?

Answer 11

BLOCKAGE of tubes

PID
Endometriosis
previous pelvic / abdominal surgery

Question 12

What is the main uterine cause of subfertility? And other secondary causes

Answer 12

FIBROIDS
Polyps
Ashermann’s syndrome (endometrial scarring)

Question 13

What are important investigations for sub fertility?

Answer 13

Blood hormone profile

• Early follicular phase FSH, LH, estradiol
• Mid luteal progesterone (confirms ovulation)

Screening:

• Chlamydia
• HIV, Hep B and C (if ART is being used)
• TVUSS

Question 14

What are two key measurements of ovarian reserve?

Answer 14

AFC - antral follicle count (seen on TVUSS)

AMH

Question 15

Why is AMH a measure of ovarian reserve?

Answer 15

Because it is produced by granulose cells in the antral follicles

So it is a biomarker of ovarian reserve

Question 16

How do you assess tubules?

Answer 16

Using hysterosalpingography

Question 17

What are medical treatments for subfertility?

Answer 17

Medical:

• ovulation induction (clomiphene/FSH)
• intrauterine insemination (with/without FSH stimulation)
• donor insemination
• IVF
• Donor egg with IVF

Question 18

What are surgical options for subfertility?

Answer 18

Operative laparoscopy - treat disease, restore anatomy
Myomectomy
Tubal surgery
Laparoscopic ovarian drilling

Question 19

How does clomiphene work?

Answer 19

It binds to oestrogen receptors in the hypothalamus / pituitary, blocking the negative feedback exerted by oestrogen
This leads to LH/FSH surge >stimulates ovary to recruit more follicles

Question 20

What is a risk for women on clomiphene?

Answer 20

They risk multiple pregnancies

Question 21

What surgical method is good for ovarian induced action in PCOS?

Answer 21

laparoscopic ovarian drilling

Question 22

How is intrauterine insemination performed?

Answer 22

Introducing a small sample of prepared sperm into the uterine cavity with a fine uterine catheter

Question 23

What kind of tracking is done to ensure there is no follicular overstimulation?

Answer 23

Follicular tracking with US

Question 24

How does IVF work?

Answer 24

1. Downregulate pituitary with GnRH agonist - this will prevent LH and FSH release > LH surge > ovulation
2. Controlled ovarian stimulation with LH, FSH (daily doses)
   3,. Inhibits premature ovulation with GnRH agonist still
3. hCG trigger (surrogate for LH surge) allows ovulation
4. Egg collection (needle into ovaries, aspirate follicular fluid + oocyte)
5. Fertilisation in Petri dish with 100k sperm
6. Embryo culture
7. Embryo transfer (transfer into uterus using soft plastic catheter)

Question 25

What is the key risk with IVF?

Answer 25

Ovarian Hyperstimulation Syndrome

Question 26

What are the four key presentations of Ovarian Hyperstimulation Syndrome

Answer 26

Monica And Octavia’s Childbirth

Multifollicular ovaries (enlarged)
Ascites
Oedema (pulmonary)
Coagulopathy