Subfertility and Infertility

Question 1

Basic information about infertility

Answer 1

• Prevalence of 1 in 6
• Investigation should start after 1 year (sometimes sooner)

Question 2

Definition in subfertility

Answer 2

• The inability of a couple to achieve a clinical pregnancy after 12 months of regular unprotected intercourse
• Primary if no previous pregnencies
• Seconary if at least on previous pregnancy
• Background conception rates:
  
  • 80% chance in 1st year
  • 90% chance in 2 years

Question 3

Factors affecting fertility

Answer 3

• Age (mostly female issue)
• Duration of sub-fertility (>3 years chance of conception <3% with each cycle)
• Timing of intercourse (sperm need to be there before ovulation)
• Female weight (conception less likely if BMI <20 or >30)

Question 4

Health promotion for fertility

Answer 4

• Smoking cessation
• Alcohol cessation
• No recreational drugs
• Healthy BMI
• Folic acid to avoid NTDs

Question 5

Male subfertility assessment

Answer 5

• Semen analysis
  
  • Sample provided after 2-5 days of abstinence
  • Analysed within 1 hour
  • Results:
    
    • Concentration >15m/ml
    • Total motility >40%
    • Normal forms >4%
    • Volume ≥1.5ml
    • Progressive motility >32%
    • Vitality - 58%
• History
• Testicular examination
• FSH
• Karyotype if severe oligospermia or azoospermia

Question 6

Terminology of semen analysis

Answer 6

• Azoospermia - absent sperm
• Oligospermia - very few sperm
• Asthenospermia - very immotile sperm
• Teratospermia - abnormal morphology

Question 7

Causes of male subfertility

Answer 7

• Defects in:
  
  • Sperm transportation
  • Sperm production
  • Hypogonadism (rare)

Question 8

Azoospermia types

Answer 8

• Obstructive azoospermia
  
  • Normal sperm production (FSH normal)
  • Normal testicular volimes
  • Sperm not present in ejaculate
• Non-obstructive azoospermia
  
  • Testicular failure (increased FSH)
  • Small testicular volumes
• Failure to stimulate spermatogenesis
  
  • Hypogonadotrophic hypogonadism
  • Low FSH
  • Around 5%

Question 9

Management of male subfertility

Answer 9

• IVF with intra-cytoplasmic sperm injection
• Donor insemination

Question 10

Assessment of female subfertility

Answer 10

• Is women releasing an egg?
  
  • If cycle regular check by mid-luteal phase progesterone
  • If irregular three groups:
    
    • 1) Hypothalamic pituitary failure
    • 2) Hypothalamic-pituitary-ovarian axis dysfunction
    • 3) Ovarian failure

Question 11

Causes of group 1 female subfertility

Answer 11

• Idiopathic
• Weight
• Stress
• Exercise
• Craniopharyngioma
• Kallman syndrome (anosmia)
• Sheehan syndrome (panhypopituitary)
• Cerebral radiotherapy

Question 12

Management of group 1 female subfertility

Answer 12

• Increase BMI and reduce exercise in moderation
• GnRH agonist
• Gonadotrophins (FSH/LH)

Question 13

Causes of group 2 female subfertility

Answer 13

• Most comon type
• PCOS
• Hyporolactinaemia
• Thyroid or adrenal dysfunction

Question 14

Diagnosis of PCOS

Answer 14

• 2 out of 3 Rotterdam criteria
  
  • Biochemical or clinical evidence of androgen excess
  • Amenorrhoea or oligomenorhoea
  • TVU features of PCOS

Question 15

Management of PCOS

Answer 15

• Weight reduction
• Drug therapy
  
  • 1st line is selective oestrogen receptor modulator (anti-oestrogenic - use for ovulation induction)
  • 2nd line is aromatase inhibitor (block oestrogen biosynthesis, increases ovulation)
• Ovarian drilling
• Assisted reproductive technology (IVF)

Question 16

Causes of group 3 female subfertility

Answer 16

• Idiopathic
• Autoimmune
• Ovarian chemotherapy/radiation/surgery
• Chromosomal

Question 17

Diagnosis and management of group 3 female subfertility

Answer 17

• Amenorrhoea, raised FSH and low oestrogen
• Some may have functional Graagin follicels but still unlikely to conceive
• Assisted conception with IVF or oocyte donation

Question 18

Tubal subfertility

Answer 18

• Problem with ovum pick-up or gamete transport
• Causes include PID and endometriosis

Question 19

Investigation of tubal subfertility

Answer 19

• Chlamydia
• TVU
• Hystero-salpingo-gram (HSG)
• Hysterosalpingo-contrast-ultrasonography (Hy-Co-Sy)
• Laparoscopy and dye test (more invasive and riskier)

Question 20

Management of tubal subfertility

Answer 20

• IVF
• If hydrosalpinges consider salpingectomy of clipping

Question 21

Forms of Assisted Reproductive Technology (ART)

Answer 21

• Ovulation induction
• IVF
• Donor sperm and donor eggs

Question 22

Eligibility criteria for IVF

Answer 22

• Co-habiting in a stable relationship for >2 years
• <42 years of age
• BMI >18.5 and <30
• Both partners non-smokers
• At least one partner with no chile
• Not sterilised