Subfertility

Question 1

How many people struggle to conceive naturally

Answer 1

1 in 7
85% will conceive after year unprotected sex

Question 2

When should investigation and referral for subfertility be done

Answer 2

Without success for 12 months
6 mobths if woman if >35

Question 3

Causes of subfertility

Answer 3

• Sperm problems (30%)
• Ovulation problems (25%)
• Tubal problems (15%)
• Uterine problems (10%)
• Unexplained (20%)
  40% of infertile couples mix male and female causes

Question 4

General advice for women trying to conceive

Answer 4

400mcg folic acid daily
Aim for healthy BMI
Avoid smoking and drinking excessive alcohol
Reduce stress at this may negatively affect libido and reslationsip
Aim for intercousre every 2-3 days
Avoid timing intercourse

Question 5

What is not necessary for intercourse for subfertility

Answer 5

Dont have to time it - stress and pressure

Question 6

Investgiations for subfertility initial

Answer 6

BMI
Chlamydia
Semen analysis
Female hormonal testing
Rubella immunity in mother

Question 7

Female hormonal testing for fertility

Answer 7

Day 2-5 of cycle - Serum LH and FSH
Day 21 - serum progesterone on day 21 cycle (or 7 dyas before if not 28 dyas)
Anti-Mullerian hormone
Thyroid function tests
Prolactin - hyperprolactonaeima cause anovulation - symptoms galactorrhea or amenorrhea

Question 8

What does high FSH suggest

Answer 8

Poor ovarian reserve (no. follicles women left in ovaries)
(pituitary gland producing extra FSH in attempt stimulate follicular development)

Question 9

What does high FSH suggest

Answer 9

Poor ovarian reserve (no. follicles women left in ovaries)
(pituitary gland producing extra FSH in attempt stimulate follicular development)

Question 10

What does high LH suggest

Answer 10

PCOS

Question 11

What does a rise in progesterone on day 21 suggest

Answer 11

Ovulation has occured, corpus luteum formed and secreting progesterone

Question 12

What does a high level of anti-mullerian hormone indicate

Answer 12

Ovarian reserve
(released by granulosa cells in follicles)

Question 13

Further investigations for PCOS

Answer 13

US pelvis
Hysterosalpingogram
Laprascopy and dye test

Question 14

What is hysterosalpingogram

Answer 14

Scan to assess shape of uterus nad patency of fallopain tubes, also therapeutic

Question 15

What happens in a hysterosalpingogram

Answer 15

Small tube -> cervix. Contrast medium injected -> uterine cavity and fallopian tubes
X rays taken - contrast outlines uterus and tibes. If dye doesnt fill one of tubes, seen on x ray, suggests obstructuion
Can also tubal cannulation - xray guidance, open up tubes

Question 15

What happens in a hysterosalpingogram

Answer 15

Small tube -> cervix. Contrast medium injected -> uterine cavity and fallopian tubes
X rays taken - contrast outlines uterus and tibes. If dye doesnt fill one of tubes, seen on x ray, suggests obstructuion
Can also tubal cannulation - xray guidance, open up tubes

Question 16

What is given prophylactically with hysterosalpingotomy

Answer 16

Antibiotics - prophylactically
Screening for chlamydia and gonorrhea done before procesdure

Question 17

What is laparascopy and dye test

Answer 17

Dye injected into uterus - should be seen -> fallopian tubes and spilling out end. Doesnt happen in tubal obstruction
Can also assess and treat endometriosis or pelvic adhesions

Question 18

What is the management of anovulation

Answer 18

Weigth loss
Clomifene - stimulate ovulation
Letrozole - 2nd line
Gonadatropins
Ovarian drilling
Metformin - insulin senstivity and obesity

Question 19

What is clomifene

Answer 19

Anti oestrogen - selective oestrogen receptor modulator. Stops negative feedback oestrogen to hypothaamus -> greater release of GnRH + therefore FSH and LH

Question 20

When are gonadotrophins used

Answer 20

Stimulate ovulation in women resistant to clomifene

Question 21

What are alternatives to clomifene

Answer 21

Letrozole - aromatase inhibitor, anti-oestrogen effects
Gonadotrophins

Question 22

Management of tubal factors

Answer 22

Tubal cannulation in HSM
Laparascopy remove adhesions/endometriosis
IVF

Question 22

Management of tubal factors

Answer 22

Tubal cannulation in HSM
Laparascopy remove adhesions/endometriosis
IVF

Question 23

Management of uterin factors

Answer 23

Surgery - correct polyps, adhesions or structural abnormalities

Question 24

When is surgical sperm retrieval used

Answer 24

Blockage along vas deferens preventing sperm reaching ejaculated seme
Needle and syring =e collect from epididymi=us through scrotum

Question 25

Options for male infertility management

Answer 25

Surgical sperm retrieval
Surgical correction obstruction
Intra-uterine insemination
Intracytoplasmic sperm injection
Donor insemination

Question 25

Options for male infertility management

Answer 25

Surgical sperm retrieval
Surgical correction obstruction
Intra-uterine insemination
Intracytoplasmic sperm injection
Donor insemination

Question 26

What is intra-uterine insemination

Answer 26

Collect and spread high quality sperm, injecting them directly into uterus to give best chance of success

Question 27

What is ICSI

Answer 27

Intracytoplasmic sperm injection
Sperm directly injected into cytoplasm of egg -> embryos, injected into uterus of woman
Significant motility issues, low sperm count etc