Subfertility (general and ovulatory dysfunction)

Question 1

Definition of subfertility

Answer 1

Conception has not occurred after a year of regular unprotected intercourse

Question 2

Reasons for subfertility

Answer 2

Ovulatory 30%
Male factor 25%
Tubal 25%
Coital 5%
Cervical 100% as more than one cause may be present

Question 3

Ovulatory dysfunction causes and investigation

Answer 3

PCOS
Hypothalamic causes
Pituitary causes
Ovarian causes (other than PCOS)
'Other' causes (thyroid; androgen-secreting tumours)
Serum progesterone in mid-luteal phase

Question 4

Ovulatory dysfunction - hypothalamus

Answer 4

↓ hypothalamic GnRH => ↓ stimulation of pituitary => ↓ LH/FSH => ↓ oestradiol. Usual in anorexia nervosa, common in women on diets, athletes and those under stress. Restoration of body weight restores function if appropriate.
Kallmann’s syndrome is when GnRH secreting neurones fail to develop
Exogenous gonadotrophins or a GnRH pump will induce ovulation
Bone protection required

Question 5

Ovulatory dysfunction - pituitary

Answer 5

Hyperprolactinameia → ↓ GnRH release
Usually due to adenomas (benign tumours) or pituitary hyperplasia
Also associated with PCOS, hypothyroidism and psychotropic drugs
Commonly have amenorrhoea/oligomenorrhoea, galactorrhoea
If pituitary tumour enlarging, headaches and bitemporal hemianopia
Elevated prolactin levels, CT if neurological symptoms
Dopamine agonist or surgery
Pituitary damage can reduce FSH/LH release, with normal GnRH. This reults from tumours or infarction following severe PPH.

Question 6

Ovulatory dysfunction - ovarian causes (excl. PCOS)

Answer 6

Premature ovarian failure: ↓ oestradiol and inhibin → ↑ FSH and LH. Exogenous oestrogen no use as no follicles to respond. Donor eggs required for pregnancy. Bone protection with HRT and COC
Gonadal dysgenesis: rare. Primary amenorrhoea
Luteinized unruptured follicle syndrome: follicle develops, egg never released. Unlikely to occur every month so does not cause persistent problem

Question 7

Ovarian hyperstimulation syndrome

Answer 7

Follicles can get very large and painful
More common during IVF
Risk factors: gonadatrophin stimulation, if this is excessive or cancellation of IVF cycle
Complications: hypovolaemia, electrolyte distyrbances, ascites, thromboembolism, pulmonary oedema, death
Management: Hospitalisation in above cases