assessment + management of infertility

Question 1

how many couples does infertility affect?

Answer 1

-it is a common condition affecting 1:6 couples

Question 2

how has the incidence of infertility changed in the past 10 years?

Answer 2

-it’s doubled in the past 10 years

Question 3

what is the WHO definition for infertility?

Answer 3

-failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse in a couple who have never had a child

Question 4

what types of infertility are there?

Answer 4

Primary and secondary

Question 5

what is primary infertility?

Answer 5

-the couple has never conceived

Question 6

what is secondary infertility?

Answer 6

-couple previously conceived, although pregnancy may not have been successful e.g. miscarriage or ectopic pregnancy

Question 7

what are some factors affecting pertility?

Answer 7

• women <30 years
• previous pregnancy
• <3 years trying to conceive
• intercourse occuring around ovulation
• womans BMI 18.5-30 m/kg
• both partners non smokers
• caffeine intake is less than 2 cups of coffee daily
• no use of recreational drugs

Question 8

what are some common causes of secondary infertility?

Answer 8

• tubal disease
• gibroids
• endometriosis/ adenomyosis
• weight related
• age related

Question 9

what are some physiological causes of anovulatory infertility?

Answer 9

• pre puberty
• pregnancy
• lactation
• menopause

Question 10

what are some gynaecological conditions causing anovulatory infertility?

Answer 10

Hypothalmic: anorexia/ bulimia, excessive exercise

Pituitary: hyperprolactinaemia, tumours, Sheehan syndrome

Overy: PCOS, premature ovarian failure

Question 11

is anorexia nervosa more common in males or females?

Answer 11

-females

Question 12

what is the aetiology of anorexia nervosa?

Answer 12

• social cultural

- genetic

Question 13

how does anorexia nervosa present?

Answer 13

• weight loss
• increased exercise
• withdrawal from friends
• amenorrhoea
• infertility
• low BMI (<18.5)
• loss of hair
• increased lanugo
• low pulse and BP
• anaemia
• dehydration
• reduced bone density
• muscle weakness and loss

Question 14

is polycystic ovary syndome (PCOS) common?

Answer 14

-yes it is the commonest endocrine disorder in women

Question 15

what is the aetiology of PCOS?

Answer 15

• its inherited

- weight gain exacerbates it

Question 16

what are some clinical features of PCOS?

Answer 16

• obesity
• hirsutism
• acne
• menstrual cycle abnormalities
• infertility

Question 17

what are some endocrine feature of PCOS?

Answer 17

• high free androgens
• high LH
• impaired glucose tolerance

Question 18

how is PCOS diagnosed?

Answer 18

must score 2 out of three:

• chronic anovulation
• polycystic ovaries
• hyperandrogenism (clinical or biochemical)

Question 19

what can cause premature ovarian failure?

Answer 19

• idiopathic
• chemotherapy
• radiotherapy
• genetic
• oophorectomy

Question 20

what are the clinical features of premature ovarian failure?

Answer 20

• hot flushes
• night sweats
• atrophic vaginitis
• amenorrhoea
• infertility

Question 21

what are some endocrine features of premature ovarian failure?

Answer 21

• high FSH
• high LH
• low oestradiol

Question 22

what are some infective causes of Tubal disease?

Answer 22

• Pelvic inflammatory disease (chlamydia, gonorrhoea, other: anaerobes, syphilis, TB)
• transperitoneal spread: appendicitis, intra-abdominal abscess
• following procedure: IUCD insertion, hysteroscopy, HSG

Question 23

what are some non infective causes of tubal disease?

Answer 23

• endometriosis
• surgical (sterilisation, ectopic pregnancies)
• fibroids
• polyps
• congenital
• salpingitis isthmica nodosa

Question 24

what is hydrosalpinx?

Answer 24

-when a fallopian tube becomes filled with fluid due to injury or infection

Question 25

what are clinical features of hydrosalpinx?

Answer 25

- abdominal/ pelvic pain - fever - vaginal discharge - cervical excitation - menorrhagia - dysmenorrhea - infertility - ectopic pregnancy

Question 26

what is endometriosis?

Answer 26

-it is an often painful disorder in which tissue similar to the tissue that normally lines the inside of your uterus — the endometrium — grows outside your uterus.

Question 27

what are causes of endometriosis?

Answer 27

- retrograde menstruation (most likely) - altered immune function - abnormal cellular adhesion molecules - genetic

Question 28

what are some clinical features of endometriosis?

Answer 28

- dysmenorrhoea - dysparenuia - menorrhagia - painful defecation - chronic pelvic pain - uterus may be fixed and retroverted - scan may show characteristic 'chocolate' cysts on ovary - infertility - asymptomatic

Question 29

what are some non obstructed causes of male infertility?

Answer 29

- chemotherapy - radiotherapy - undescended testes - idiopathic

Question 30

what are the endocrine features of non obstructive male infertility?

Answer 30

- high LH and FSH | - low testosterone

Question 31

what are some causes of obstructive male infertility?

Answer 31

- congenital absence (e.g. cystic fibrosis) - infection - vasectomy

Question 32

what are the endocrine feature for obstructive male infertility?

Answer 32

-normal LH, FSH and testosterone

Question 33

what are investigations of infertility in females?

Answer 33

- endocervical swab for chlamydia - cervical smear if due - blood for rubella immmunity - midluteal progesterone level - test of tubal patency (hysterosalpingiogram or laparoscopy)

Question 34

when is a hysteroscopy performed?

Answer 34

-only performed in cases where suspected or known endometrial pathology

Question 35

when would a pelvic ultrasound be performed?

Answer 35

-when there is an abnormality on pelvic examination (e.g. enlarged uterus)

Question 36

what are some infertility investigations in males?

Answer 36

- semen analysis (twice over 6 weeks apart) - scrotal ultrasound - LH, FSH, testosterone, prolactin, thyroid function (endocrine profile) - chromosome analysis - testicular biopsy - screen for cystic fibrosis

Question 37

what is lifestyle advice for a couplet trying to conceive?

Answer 37

- stop smoking - achieve BMI between 18.5 and 30 - reduce alcohol - try drink less caffeinated drinks - stop taking recreational drugs - stop methadone

Question 38

does weight have an effect on miscarriage rate and fertility problems in women?

Answer 38

yes - overweight women have an increase in fertility problems and higher miscarriage rate

Question 39

what are some examples of vitamin tablets that may be prescribed for pregnancy?

Answer 39

- folic acid | - vitamin D

Question 40

when is folic acid given for pregnancy?

Answer 40

400mcg daily before pregnancy and throughout the first 12 weeks

Question 41

what is the management of hypothalamic anovulation?

Answer 41

- Stabilise weight (BMI>18.5) - Pulsatile GnRH to induce ovulation in hypothalamic amenorrhoea - Gonodotrophin (FSH + LH) daily injections (both need regular ultrasound monitoring of ovarian response)

Question 42

what are symptoms of PCOS?

Answer 42

- irregular menstrual cycle - hirsutism - acne - subfertility - alopecia - obesity

Question 43

what biochemical markers are found in someone with PCOS?

Answer 43

- elevated serum LH (>10 IU/L) - LH/ FSH ratio >2 - normal estradiol - low progesterone - normal or mildly elevated progesterone - raised testosterone

Question 44

what may be seen on a transvaginal USS of someone with PCOS?

Answer 44

-polycystic ovarian morphology

Question 45

what is the treatment for PCOS?

Answer 45

first line= ovulation induction this can be done using a number of treatments such as: - Antioestrogens (clomifene citrate and tamoxifen) - Aromatose inhibitors (letrozole) second line= laparoscopic ovarian drilling

Question 46

what is the risk of gonadotrophin therapy?

Answer 46

- multiple pregnancies | - ovarian hyperstimulation syndrome (OHSS) which is when the ovaries swell and become painful

Question 47

what is the risk of laparoscopic ovarian diathermy?

Answer 47

-risk of ovarian destruction/adhesions resulting in mainly singleton pregnancies

Question 48

what is hydrosalpinx?

Answer 48

when the fallopian tube becomes filled with fluid due to injury or infection

Question 49

what is myosure instrument used for?

Answer 49

-removing polyps

Question 50

what is a uterine septum?

Answer 50

-a condition where the uterus gets an extra wedge of tissue