Infertility and Sub fertility

Question 1

Define Infertility?

Answer 1

An inability of a couple to conceive after 12 months of regular intercourse without of contraception

Question 2

What is the chance of couples conceiving within 1 year?

Answer 2

80% of couples in the general population will conceive within one year if the women is under 40 and the couple do not use contraception/have regular sexual intercourse

Question 3

What history should be taken from the female?

Answer 3

Duration of infertility, previous contraception, fertility in previous relationships, previous pregnancies and complications, menstrual history, medical and surgical history, sexual history, previous investigations, psychological assessment

Question 4

What examination should be performed on a female?

Answer 4

Weight, height, BMI, Ft and Hair distribution, Galactorrhoea, Abdo Examination, Pelvic Examination

Question 5

What are the baseline investigations for female infertility?

Answer 5

Rubella immunity, chlamydia, TSH, check regularity of periods and mid luteal progesterone (day 21-28)

irregular periods= FSH Levels, TSH levels, LH Levells, PR levels and testosterone on day 1-5 of cycle

Question 6

What investigations are performed at the fertility clinic?

Answer 6

Pelvic ultrasound, physical examination, ovulation testing, semen analysis, tubal patency test

Question 7

How can you assess ovulation?

Answer 7

Blood test to measure serum progesterone in the mid luteal phase of their cycle to confirm ovulation

Question 8

How do you assess ovulation in irregular menstrual cycle?

Answer 8

Blood test to measure serum progesterone during late cycle (28-35 days)

FSH and LH should be measured

Question 9

What history should be taken from the male?

Answer 9

Check development - Testicular descent, change in shaving frequency, loss of body hair,

Check infection history - mumps, STDs.

Check surgical history- varicocele repair vasectomy,

Lifestyle questions - previous fertility, alcohol, smoking, anabolic steroids, chemotherapy, radiation, recreational drugs, libido-sexual drive, frequency of intercourse, previous fertility assessment, any history of chronic medical illness

Question 10

What examination should be performed on a male?

Answer 10

Weight, Height,BMI, Fat and Hair Distribution, Abdo and Inguinal Examination, Genital Examination

Question 11

How are ovulatory disorders classified?

Answer 11

Group I - hypothalamic pituitary failure
Group II - Hypothalamic- pituitary- ovarian dysfunction (PCOS)
Group III - ovarian failure (primary ovarian insufficiency)

Question 12

How can one attempt to improve the ovulation of someone who suffers from a Group I ovulation disorder?

Answer 12

Increase BMI to >19 and or moderating exercise levels if they undertake high levels of exercise

Offer pulsatile administration of GnRH or gonadotrophins with LH to induce ovulation

Question 13

What are the characteristics of PCOS?

Answer 13

Androgen excess, infrequent periods, polycystic ovaries

Question 14

What medication can induce ovulation?

Answer 14

Clomifene and Gonadotrophins

Question 15

How does clomiphene induce ovulation?

Answer 15

By blocking estrogen receptors in the anterior pituitary = increased secretion of FSH

Question 16

What clinical assessments should be performed on a woman with apparent hirsutism?

Answer 16

Ferriman Gallwey Score

Look for acanthosis nigricans

Question 17

What biochemical measurements should be performed on a woman with a suspected androgen excess?

Answer 17

Testosterone
DHEAS levels (if > 700mcg/dL then CT for adrenal tumour)
17-OH progesterone

Question 18

What may be found on the pelvic examination?

Answer 18

Masses
Pelvic Distortion
Tenderness
Vaginal Septum
Cervical abnormalities
Fibroids

Question 19

How should suspected tubal occlusion be investigated ?

Answer 19

hysterosalpingography

Question 20

What symptoms are suggestive of male androgen deficiency ?

Answer 20

Increased body fat
Decreased muscle mass
Loss of pubic, axillary and facial hair

Question 21

What is the most common cause of hypogonadism?

Answer 21

Kleinfelter syndrome - small testes, azoospermia

XXY chromosomal patern

Question 22

What causes bilateral absence of the vas deferens?

Answer 22

CF in males

Question 23

What is the lower laboratory reference value for sperm volume?

Answer 23

1.5 ml

Question 24

What is the lower laboratory reference value for sperm concentration?

Answer 24

15 millions/ml

Question 25

What is the lower laboratory reference value for total sperm number?

Answer 25

39 Millions

Question 26

What is the lower laboratory reference value for progressive motility?

Answer 26

32%

Question 27

What is the lower laboratory reference value for total motility?

Answer 27

40%

Question 28

What is the lower laboratory reference value for sperm to appear morphologically normal?

Answer 28

4%

Question 29

How does clomifene work?

Answer 29

By blocking oestrogen receptors in the anterior pituitary = increased FSH

Question 30

What should be considered if the male is the causative factor of infertility?

Answer 30

IVF
Intracytoplasmic Sperm Injection
IU insemination
Surgery - sperm retrieval 
Donor insemination

Question 31

What should be done if the woman has unexplained fertility?

Answer 31

DO NOT OFFER ORAL OVULATION STIMULATION AGENTS

advise woman to try for 2 years in total then offer IVF

Question 32

What should be done if the woman is the causative factor of infertility?

Answer 32

IVF
Oral ovulation stimulation agents
Tubal surgery

Question 33

How is IVF carried out?

Answer 33

1. Eggs are harvested from ovary
2. Eggs fertilised in lab with sperm
3. Embryos undergo a number of cell divisions
4. Embryos transferred into the womb

Question 34

What is ICSI?

Answer 34

Injection of mature eggs with single sperm
Embryo transferred into uterus
Embryo can be frozen