Subfertility 1

Question 1

What are important questions to ask women when taking a fertility history?

Answer 1

Menstrual history 
Previous pregnancies 
Contraception 
History of pelvic inflammation or abdominal surgery 
Drugs

Question 2

What are important questions to ask men when taking a fertility history?

Answer 2

puberty 
prev fatherhood 
prev surgeries (hernias, orchidopelxy) 
illnesses 
drugs
alcohol intake 
occupation (is he home at ovulation time)
erectile problems

Question 3

What are important questions to ask both men and women when taking a fertility history?

Answer 3

mood 
feelings about infertility 
technique 
frequency and timing of intercourse
parenthood 
prev tests

Question 4

What are the hormonal changes around early pregnancy?

Answer 4

low oestrogen levels stimulates FSH and LH release
FSH and LH initiate maturation of several follicles and an intermediate amount of oestrodiol
less FH and LH are produced
Development of mature follicle suppresses FSH
As follicle matures more oestradiol is produces and LH and FSH are released
Follicle ruptures releasing an oocyte, remaining becomes the corpus luteum
Corpus luteum releases oestrogen and progesterone to maintain endometrium
hCG produced by trophoblastic tissue acts on corpus luteum until 8-10 weeks gestation

Question 5

What is primary infertility?

Answer 5

infertility without previous pregnancy or live birth

Question 6

What is secondary infertility?

Answer 6

failure to conceive after 1 or more pregnancies (successful or not)

Question 7

What are the different causes of infertility?

Answer 7

ovulation problems 
sperm quality problems 
blocked fallopian tubes
unexplained infertility 
endometriosis 
other

in many couples there are multiple reasons

Question 8

What are the different types of ovulation disorders?

Answer 8

type 1 - hypogonadal hypogonadism (rare)
type 2 - normogonadotrophic anovulation (usually PCOS)
type 3 - hypergonadotrophic hypogonadism
type 4 - hyperprolactinaemia

Question 9

What is the most common cause of tubal disfunction?

Answer 9

infection - acute salpingitis causing occlusion of the fimbrial end with collections in tubal lumen
most likely caused by chlamydia

Question 10

What other diseases cause tubal disfunction?

Answer 10

appendicitis, peritonitis, crohns or UC can causes peritubal adhesions and per-ovarian adhesions

any damage to internal structures of the tube can remove function

Question 11

What uterine factors affect fertility?

Answer 11

distortion - submucous fibroids or congenital abnormalities make implantation less likely
adenomyosis linked to recurrent implantation failure
Intrauterine adhesions can affect implantation

Question 12

How does endometriosis affect fertility?

Answer 12

severe disease - large ovarian cysts, extensive adhesions leads to subfertility

mild disease also linked to subfertility

surgical treatment can help

Question 13

What are the cervical factors influencing fertility?

Answer 13

cervical infection or antisperm antibodies in cervical mucous or seminal plasma inhibit sperm penetration

Question 14

What are the different ways in which infertility in females can be investigated?

Answer 14

menstrual history - if regular look at hormone level changes
transvaginal US of ovaries used to track follicle growth and diagnose PCOS or ovarian endometrioma

Question 15

What should you measure in anovulation?

Answer 15

serum FSH, LH, oestradiol and AMH on day 2/3 of the menstrual cycle
serum prolactin
thyroid function
MRI or CT of sella turcica if prolactin released

Question 16

How do you measure ovarian reserve?

Answer 16

AMH in serum to determine +/- antral follicle count with transvaginal USS
Low AMH or AFC suggests poor oocyte yield with IVF
Can’t identify quality of oocytes, usually linked to age

Question 17

What investigations can be used to identify tubal patency?

Answer 17

hysterosalpingography - injection of contrast into uterus and fallopian tubes

Hysterosonocontrast sonography - use transvaginal USS for a real time filling

Laporoscopy and dye insufflation - direct visualisation, test tubal patency by injecting dye

Question 18

What is the first line treatment of anovulation?

Answer 18

clomiphene citrate
produces ovulation in 80% of subjects and pregnancy in half of those

given on day 2-6 and monitor ovulation and monitor follicle growth on USS

Question 19

What is the second line treatment for anovulation?

Answer 19

laporoscopic ovarian diathermy (LOD) ~70% induction of ovulation

drug free and lower risk of multiple pregnancy

Question 20

How is tubal pathology treated?

Answer 20

IVF has replaced surgery almost completely

all surgery increases the risk of ectopics

Question 21

What is intrauterine insemination?

Answer 21

soft catheter and low dose gonadotropin to stimulate ovulation
live birth rate 15-20% per cycle
more cost effective than IVF
good for coital dysfunction or cervical mucus abnormality

Question 22

How does IVF and embryo transfer work?

Answer 22

stimulation of development of multiple ovarian follicles using gonadotrophins and GnRH agonists
collect oocytes using transvaginal USS guided needle aspiration
culture fertilised oocytes for up to 5 days, then best blastocytes are transferred to the uterine cavity

Question 23

What is the main outcome determinant?

Answer 23

female age

increasing numbers will use donated oocytes from younger women

Question 24

What are the major problems with IVF pregnancies?

Answer 24

multiple pregnancy

premature birth

Question 25

What is ovarian hyperstimulation syndrome?

Answer 25

overdose with gonadotrophins - OHSS - excessive follicle development, high circulating oestrogen concerntrations and VEGF

potentially lethal

Question 26

What are the consequences of severe ovarian hyperstimulation syndrome?

Answer 26

ovarian enlargement 
fluid shift and ascites 
pleural effusion 
sodium retention 
oliguria 

may become hypovolaemic, hypotensive, can develop renal failure, ARDS and VTE

Question 27

How is ovarian hyperstimulation syndrome managed?

Answer 27

mild can be managed conservatively
severe can give human albumin and drain fluid to decrease load
ACEIs may be indicated