Infertility

Question 1

What is the definition of infertility?

Answer 1

inability of the heterosexual couple to achieve clinical pregnancy within 12 months of beginning regular unprotected sexual intercourse

Question 2

What are risk factors affecting fertility?

Answer 2

Age,
Previous pregnancy,
Duration of sub-fertility,
Timing of intercourse,
Weight - Less likely if BMI < 18.5 or > 30

Question 3

What are the types of azoospermia?

Answer 3

1. Obstructive (normal spermatogenesis but inability to leave in ejaculate). Block in vas or epididymis or absence of vas.
2. Non obstructive (testicular failure). Take biopsy, check for Klinefelter’s syndrome. May also have hypogonadotrophic hypogonadism

Question 4

What are the different classes of ovarian failure

Answer 4

Group 1. Amenorrhoea due to low endogenous gonadotrophins. Hypothalamic pituitary failure.
Group 2. Anovulation associated with menstrual disorders (PCOS). HPO axis dysfunction.
Group 3. Amenorrhoea due to ovarian failure

Question 5

What is the management of fertility in PCOS?

Answer 5

Weight loss is the mainstay of treatment.
Ovarian drilling,
Letrozole 1st line medical therapy. Low risk of multiple pregnancy.
Clomiphene. Higher risk of multiple pregnancy and ovarian CA.
IVF
Metformin

Question 6

What are the investigations and management of group 1 amenorrhoea?

Answer 6

• Low FSH and LH and oestrogen.
• Increase BMI, reduce excercise, treat underlying cause.
• GnRH agonist pump
• Gonadotrophins

Question 7

How can you assess tubal patency?

Answer 7

First line - Hysterosalpingo-contrast-ultrasonography (Hy-Co-Sy)
Hysterosalpingogram
Laparoscopy and dye test - Gold standard

Question 8

What are some techniques for assisted fertilisation?

Answer 8

Intrauterine insemination +/- ovulation induction.
In vitro fertilization
Intracytoplasmic sperm injection (a single sperm is injected into a mature egg)

Question 9

What are the causes and management of group 3 amenorrhoea?

Answer 9

There will be high FSH but low oestrogen
Idiopathy,
Chemotherapy,
Surgical removal of ovaries,
Autoimmune,
Chromosomal,
Turners syndrome,
Androgen insensitivity
Management - IVF with oocyte donation, embryo donation, adoption, fostering and accepting childlessness.

Question 10

What are the basic investigations for infertility?

Answer 10

Semen analysis,
Serum progesterone 7 days prior to expected next period. If below16 nmol/l then repeat, if consistently low then refer to specialist

Question 11

Explain ovarian hyperstimulation syndrome

Answer 11

Ovaries over respond to gonadotrophin injections. This results in a systemic disease resulting from release of vasoactive products. This causes increased membrane permeability and loss of fluid from intravascular compartment.

Presentation - thrombosis, renal dysfunction, liver dysfunction, ARDS, ascites, pleural effusions.

Treatment - Supportive and careful fluid balance

Question 12

What is some health promotion advice for subfertile couples?

Answer 12

Reduce smoking - Reduced female fertility and sperm quality.
Alcohol - reduce! 1/2 units per week but try reduce all.
Recreational drugs - especially body building supplements.
Obesity - Reduced fetility in men as well.
Low BMI with oligomenorrhoea,
Folic acid