Subfertility NICE CG156 - first line investigations

Question 1

What is the incidence of natural conception within the general population after trying to conceive for 1 year and the woman is under the age of 40?

Answer 1

80%

Question 2

What is the cumulative natural conception rate within the general population after trying to conceive for 2 years and the woman is under the age of 40?

Answer 2

90%

Question 3

What is the incidence of conception for women under 40 with 6 cycles of intrauterine insemination?

Answer 3

> 50%

Question 4

What is the cumulative pregnancy rate for women under 40 with 12 cycles of intrauterine insemination?

Answer 4

75%

Question 5

What type of sperm has higher pregnancy rates with Intrauterine insemination?

Answer 5

Fresh sperm has higher pregnancy rates than frozen-thawed sperm

Question 6

Which artificial insemination procedure is associated with higher pregnancy rates?

Answer 6

Intrauterine insemination has higher pregnancy rates than intracervical insemination

Question 7

How often should couples have sexual intercourse to try to conceive?

Answer 7

2-3 X per week

Question 8

How much alcohol should couples trying to conceive drink?

Answer 8

Women – max 1-2 units 1-2 x per week

Men – max 3-4 units per day

Question 9

What should couples trying to conceive be advised about smoking?

Answer 9

Women – advised smoking reduces fertility even passive smoking and refer to smoking cessation
Men – evidence that smoking reduces sperm quality but impact on male fertility is uncertain

Question 10

What should couples trying to conceive be advised about BMI?

Answer 10

Women BMI >/=30 – will take longer to conceive
Women BMI >/= 30 and irregular periods/not ovulation – weight loss will improve chance of conception
Women BMI =19 and irregular periods – weight gain will improve chance of conception
Men BMI >/=30 – they are likely to have reduced fertility

Question 11

Which patients are recommended to take 5mg folic acid?

Answer 11

Previous neural tube defect
Epilepsy
Diabetes

Question 12

What lifestyle measures can be used to improve a couples chance of conception?

Answer 12

Weight control – increase if 19 or less, reduce if >/= 30
Regular intercourse 2-3 x per week
Alcohol intake control (1-2 units 1-2 x per week women)
Smoking cessation
No evidence that caffeine affects fertility

Question 13

For women under the age of 36, when should the couple be referred for fertility investigations?

Answer 13

After 12 months of regular sexual intercourse

After 6 cycles of artificial insemination

Question 14

13) When should couples have an early referral for fertility investigations?

Answer 14

Women 36 years or older
When there is a known cause of subfertility or possible pre-disposing factors
Cancer treatment is planned which would affect fertility

Question 15

What are the normal parameters for semen analysis? volume?

Answer 15

> /= 1.5ml

Question 16

What are the normal parameters for semen analysis? concentration?

Answer 16

> /= 15 million/ml

Question 17

What are the normal parameters for semen analysis? ph?

Answer 17

> /= 7.2

Question 18

What are the normal parameters for semen analysis? total sperm number?

Answer 18

> /= 39 milliion per ejaculate

Question 19

What are the normal parameters for semen analysis? motility?

Answer 19

> 40% motile or 32% progressively motile

Question 20

What are the normal parameters for semen analysis? vitality?

Answer 20

> /= 58% alive

Question 21

What are the normal parameters for semen analysis? morphology?

Answer 21

> /= 4% normal morphology

Question 22

What should you do if first semen analysis is abnormal

Answer 22

Repeat the semen analysis

In 3 months or as soon as possible if there are no sperm or very low sperm count

Question 23

What tests should not be carried out as initial fertility investigations?

Answer 23

Anti-sperm antibodies (relevance uncertain)
Post cervical cervical mucus
Ovarian volume or blood flow to predict IVF success
Inhibin B or oestradiol to predict IVF success
Routine prolactin and thyroid levels
Endometrial biopsy to assess luteal phase
Hysteroscopy as a first line investigation

Question 24

What is the first line predictor of success of natural conception and IVF?

Answer 24

Maternal age

Question 25

18) What is the annual fertility rate from natural conception for women aged 25-29, aged 30-34, aged 35-39, aged 40-44, age 45 and above?

Answer 25

25-29              45-48% 
30-34              40-45% 
35-39              35-40% 
40-44              10-30% 
45+                  <10%

Question 26

Which measures can be used to predict a woman’s response to gonadotrophins simulation in IVF?

Answer 26

Total antral follicle count
Anti-mullerian hormone
FSH

Question 27

What predicted as a low response and a high response result for total antral follicle count?

Answer 27

Predicted low response = 4

Predicted high response >/= 16

Question 28

What predicted as a low response and a high response result for anti-mullerian hormone?

Answer 28

Predicted low response = 5.4 pmol/l

Predicted high response >/= 25pmol/l

Question 29

What predicted as a low response and a high response result for FSH?

Answer 29

Predicted low response = 8.9 IU/l

Predicted high response >/= 4 IU/l

Question 30

Who should prolactin be measured in?

Answer 30

Women with an ovulatory disorder
Galactorrhoea
Known pituitary tumour

Question 31

Which women should be offered HSG and which women should be offered lap dye test?

Answer 31

HSG – no known co-morbidities to assess tubal patency

Lap dye test – known or suspected endometriosis, previous ectopic pregnancy, PID

Question 32

Which tests are performed to investigate female factor infertility?

Answer 32

Blood tests – all women should have a mid-luteal phase progesterone, if ovulation disorder/known pituitary tumour/galactorrhoea - test prolactin, if menstrual irregularity – test LH and FSH, if signs of thyroid dysfunction test thyroid

Viral screen pre IVF – HIV, Hep B, Hep C

HSG if no comorbidities, lap dye test if suspected or known endometriosis, ectopic pregnancy, PID

Question 33

Which tests are performed to investigate male factor infertility?

Answer 33

Semen analysis

Question 34

What is the role of rubella testing and vaccination?

Answer 34

Test for rubella and those who are susceptible should be offered vaccine and should not fall pregnant within 1 month of the vaccine

Question 35

What factors reduce the risk of HIV transmission from a male HIV positive partner to female HIV negative partner to “negligible levels”?

Answer 35

Viral count <50 copies/ml
Compliant with HAART
No other infection present
Unprotected Intercourse just around time of ovulation

Question 36

Who do you offer sperm washing for?

Answer 36

Pre insemination when the man is HIV positive and is not compliant with HAART, or plasma viral count >50 copies/ml
Or the risk of HIV transmission is low but still unacceptable for the couple
Sperm washing lowers likelihood of pregnancy
Do not offer for patients with hepatitis B

Question 37

When might post-exposure prophylaxis for HIV be considered?

Answer 37

No evidence for its use in couples that meet low risk of transmission criteria

Question 38

What should be provided to couples where one of the partners is hepatitis B positive?

Answer 38

Hepatitis B vaccine to unaffected partner before fertility treatment

Question 39

What proportion of subfertility is unexplained?

Answer 39

25% (NICE) 30-40% (TOG16)

Question 40

What proportion of subfertility is male factor?

Answer 40

30%

Question 41

What proportion of subfertility is tubal factor?

Answer 41

20%

Question 42

What proportion of subfertility is caused by ovulatory disorders?

Answer 42

25%

Question 43

What proportion of subfertility is caused by uterine and peritoneal disorders?

Answer 43

10%

Question 44

What proportion of subfertility is caused by both female and male factors?

Answer 44

40%