Female Factor Infertility

Question 1

What are the main causes of female factor infertility

Answer 1

Anovulatory
Tubal Damage
Uterine Abnormalities
Endometriosis
Miscellaneous e.g. Turners, medications, psychosexual

Question 2

Describe the types of anovulatory infertility and give examples.

Answer 2

WHO group 1 - hypothalamic/pituitary failure e.g. IHH, Kallman’s, low body weight, stress, excessive exercise, intracranial tumour
WHO group 2 - hypothalamic/pituitary dysfunction e.g. PCOS
WHO group 3 - ovarian failure e.g. POF, turners can come into this category as it can cause POF
WHO group 3 - hyperprolactinaemia

Question 3

what is PCOS

Answer 3

a condition which is present in 5 percent of reproductive aged women and is a common cause of oligo-amenorrhea
characterised by disrupted follicular genesis, excess of androgens and insulin resistance

Question 4

what is the diagnostic criteria of PCOS

Answer 4

Rotterdam 2 of 3:

• polycystic ovaries on ultrasound - either more than or equal to 12 antral follicles in one ovary or an enlarged ovary more than or equal to 10ml
• evidence of hyperandrogenism
• oligo/anovvulation

Question 5

what is premature ovarian failure

Answer 5

menopause before the age of 40

diagnosed by 2 FSH levels greater than 30mlU/ml one month apart.

Question 6

what can cause hyperprolactinaemia

Answer 6

pituitary adenoma

antipsychotic medications

Question 7

what can cause tubal damage

Answer 7

chlamydia
endometriosis
peritubal adhesiosn from surgery
history of previous ectopic suggest likely ongoing tubal damage

Question 8

what uterine abnormalities exist

Answer 8

fibroids - submucosal, intramural, subserosal - submucosal more likely to affect fertility as they disrupt implantation
abnormal uterine shapes e.g. bicornate, double uterus/vagina

Question 9

How are fibroids treated

Answer 9

hormonally dependent so may increase in size during IVF/pregnancy
can be removed if large and symptomatic >3cm is typical cut off
can be removed to improve fertility

Question 10

what is endometriosis

Answer 10

presence and proliferation of endometrial tissue out with the uterine cavity
most likely due to retrograde menstruation with subsequent implantation and oestrogen derived growth of deposits
four grades; minimal, mild, moderate, severe

Question 11

what is the name of a cyst of endometriosis of ovary

Answer 11

endometrioma

Question 12

what is the reasons for reduced fertility with increasing maternal age

Answer 12

increase proportion of aneuploidy oocytes

this will be more likely to result in an aneuploidy embryo and thus miscarry

Question 13

What test is done to assess ovulation in women with regular periods

Answer 13

mid luteal progesterone
should be done approx. 7 days before next mensturation
normal level is more than 16nmol/l -consistent with ovulation

Question 14

what test is done to assess ovulation/anoulation in women with irregular periods

Answer 14

FSH, LH, testosterone, thyroid function, prolactin
FSH normal - PCSO
FSH high - POF
FSH low- IHH, over exercise, stress, low BMI

Question 15

What are the methods of assessing tubal patency

Answer 15

HSG
Laparoscopy and dye
Hysterocontrasty-ultrasonography (HyCoSy)

Question 16

What is HSG and who would get this investigation

Answer 16

this is first line for most women to assess tubal patency
should be done after menstruation and befpre ovulation incase there is pregnancy
involves injecting radiopaque dye into uterine cavity followed by taing a series of x ray images

Question 17

how sensitive is HSG

Answer 17

80 percent sensitive to diagnosin tubal patency

Question 18

why might a hsg show a wrong result

Answer 18

the dye can cause spasming of fallopian tubes and make them appear occluded when they are not

Question 19

what are the risks of HSG

Answer 19

painful
false results
possibility of introducing infection into pelvis - screen for STIs prior to procedure or give antibiotics if unscreened

Question 20

what is done if HSG is abnormal

Answer 20

laparoscopy

Question 21

What is laparoscopy and dye

Answer 21

performed under general anaesthetic
inflate abdomen with CO2 inspect pelvis laparosccally with camera inserted through port in umbilicus
dye is injected into cervix via a catheter and the fallopian tubes are seen to fill with dye and spill some dye into the pelvis if patent

Question 22

what are the advantages of laparoscopy and dye

Answer 22

you can visualise pelvis for endometriosis, adhesions, fibroids
opportunity to deal with some of these is they are present and not too severe

Question 23

What patients would receive a laparoscopy rather than HSG

Answer 23

history of PID
history of ectopic pregnancy
endometriosis

Question 24

What is hycosy

Answer 24

ultrasound opaque liquid injected into uterine cavity and ultrasound used to visualise
not done in ninewells