Infertility

Question 1

General recommendations to help fertility?

Answer 1

Preconceptional Supplements (folic acid and vitamin D)
Environmental factors (occupation/drugs)
Stop smoking
Females no alcohol, male limit alcohol
BMI - female <19 >30 is bad, male >30 is bad

Question 2

How much sex to optimise fertility?

Answer 2

Every 2/3 days

Question 3

Four types of infertility and their prevalence?

Answer 3

Anovulatory - 30%
Male factor - 35%
Tubal factor - 30%
Unexplained - 15%

Question 4

Three types of anovulatory disorder?

Answer 4

Ovarian - PCOS, premature ovarian insufficiency
Pituitary - hyperprolactinaemia, hypopituitarism
Hypothalamic - hypogonadism

Question 5

Causes of hypothalamic hypogonadism?

Answer 5

(Low FSH, v low LH, low oestrogen)

oWeight loss and over-exercise
o Systemic illness
o Idiopathic Hypogonadotropic hypogonadism
o Kallman’s syndrome – GnRH secreting neurones fail to develop.

Question 6

What is GnRH level in hypopituitarism?

Answer 6

GnRH normal - can result from tumours, or infarction following Sheehan’s syndrome.

Question 7

What do you do in hyperprolactinaemia?

Answer 7

(Reduces GnRH release –> Low FSH, low LH, Low oestrogen)

Give dopamine agonist
• 85% will get restored ovarian function
• 85% will conceive
• If cause is macroadenoma, 50% will concieve

Question 8

Ways of detecting ovulation?

Answer 8

• Mid-luteal phase serum progesterone (standard test)
• USS follicular tracking (time-consuming)
• Temperature charts (not recommended)
• LH-based urine predictor kits (ovulation should follow LH surge)

Question 9

3 groups of ovulatory disorder?

Answer 9

• Group I: hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism).
• Group II: hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome).
• Group III: ovarian failure.

Question 10

Clinical features of Group 1

(Hypogonadotrophic/ Hypothalamic hypogonadism)?

Answer 10

1. Low energy availability/ eating disorders
2. Low bone mass
3. Menstrual disturbance
   (Female athlete triad)

Question 11

Hormone levels in Group 1 disorder?

Answer 11

Oestrogen = Low
FSH = low/ normal

Question 12

Management of group 1 disorder?

Answer 12

If BMI <19 – increase weight.
If high exercise levels – moderate exercise.
Gonadotrophins for ovulation induction.

Question 13

Clinical features of group 2 (PCOS)?

Answer 13

1. Polycystic ovaries on USS
2. Clinical/biochemical hyperandrogenism
3. Oligo/anovulation
   (Rotterdam criteria)

At increased risk of developing hypertension, diabetes and sleep apnoea later in life.

Question 14

Hormone levels in PCOS?

Answer 14

Oestrogen = Low
FSH = low/ normal
Oestrogen = normal
FSH = normal

Question 15

Management of PCOS?

Answer 15

Clomifene
Metformin
Gonadotrophins
Ovarian diathermy

Question 16

What is clomifene?

Answer 16

• 1st line in PCOS – oestrogen receptor blocker –> increases FSH/LH (fools pituitary into thinking there is no oestrogen) – given from day 2 to day 6. Limited to 6 months’ use.
• Multiple pregnancy more likely

Question 17

Which two treatments for PCOS make multiple pregnnacy more likely/

Answer 17

Clomifene

Gonadotrophins

Question 18

Clinical features of group 3 (premature ovarian insufficiency)?

Answer 18

1. Oligo/amenorrhoea for at least 4 months
2. Elevated FSH level >25 IU/L on two occasions >4 weeks apart
3. Low oestrogen (vasomotor symptoms, osteoporosis)

(Loss of ovarian activity before 40 years)

Question 19

Hormone levels in group 3 (premature ovarian insufficiency)?

Answer 19

Oestrogen = low
FSH = high

Question 20

Tests in group 3 disorders?

Answer 20

Karyotype – Turner Syndrome (45X) –> Refer to endocrinologist, cardiologist and geneticist

Karyotype – Chromosomal Material –>Discuss gonadectomy

Fragile X –> Refer to geneticist (Implication to family members)

Anti-adrenal antibodies –> Refer to endocrinologist

Thyroid peroxidase antibodies –> Test TSH every year

Question 21

Fertility treatment for premature ovarian failure/

Answer 21

Fertility Treatment
•	Oocyte donation
•	No interventions shown to increase ovarian activity and natural conception rates
.
Hormone replacement therapy

Question 22

What is ovulation induction?

Answer 22

• Aim – unifollicular growth
o Timed with urinary LH/hCG administration
o Timed sexual intercourse.

Question 23

Risk factors for primary ovarian insufficiency?

Answer 23

• Modifiable Risk Factors
o Gynae surgical practice
o Stop smoking
o Modified treatment regimens.

•	Non-modifiable risk factors
o	Chromosomal (e.g. Turner’s XO)
o	Fragile X
o	FNA e.g. BPES
o	Adrenocortical/thyroid antibodies
o	Idiopathic

Question 24

Consequences of premature ovarian insufficiency?

Answer 24

Reduced life expectance due to cardiovascular disease
 Atherosclerosis
 Turner’s associated with congenital DVS

Decreased bone mineral density
 No oestrogen – need DEXA scan, healthy lifestyle and vitamin D
 Can give HRT – you are supplementing what isn’t there so is not dangerous.

Fertility – small chance of pregnancy – need contraception

Question 25

Types of male factor infertility

Answer 25

* Oligozoospermia = <15 million sperm * Asthenzoospermia = reduced sperm motility * Teratozoospermia = abnormal sperm morphology

Question 26

Causes of male factor infertility?

Answer 26

Most causes not reversible o Idiopathic (most common cause) o Hypogonadism (10%) o Genetic causes (Needs to be excluded before ICSI) - CF o Testicular trauma / surgery / developmental abnormalities (cryptorchidism) o Obstructive (surgery – vasectomy / infection) o Anabolic steroid induced (not always be reversible) o Previous chemotherapy / radiation

Question 27

What is the only medically treatable cause of male factor infertility?

Answer 27

Hypogonadism (low FSH/LH)  Stop drugs – anabolic steroids most common cause. • No guarantee it will come back  Treat hyperprolactinaemia  Pulsatile gonadotrophing and hCG  Testosterone alone will not induce spermatogenesis • Must have LH and FSH

Question 28

Causes of tubal factor infertility?

Answer 28

``` o PID (chlamydia) o Endometriosis o Past abdominal/pelvic infection or surgery (appendicitis) o Treatment to cervix o Fibroids/polyps ```

Question 29

Investigations in tubal factor infertility?

Answer 29

o Hysterosalpingography  Appropriate for low risk women o Hysterosalpingo-contrast-ultrasonography  Alternative to HSG with no radiation exposure o Laparoscopy  The gold standard o Always screen for chlamydia and other pathogens before test.

Question 30

When is IVF recommended?

Answer 30

If all other causes are excluded, IVF is recommended after two years of trying.

Question 31

What is intrauterine insemination?

Answer 31

o Follicle development tracked ultrasonographically o Sperm prepared o Placed in uterine cavity with USS

Question 32

What is the aim of IVF?

Answer 32

oAim for: controlled multi-follicular growth

Question 33

What is the process for IVF?

Answer 33

 Hormones (gonadotrophins) taken by the woman as injections cause the ovary to make several eggs at the same time (multifollicular recruitment)  Egg collection 36 hours later (Sedated transvaginal procedure)  Oocytes and sperm incubated together overnight • The fertilised eggs (embryos) grow under observation in the laboratory for two to six days • Selection process - to identify embryo(s) with the best chance of continuing to develop into a baby  Embryo transfer to uterus (like a smear test)  Give woman progesterone for luteal support  Pregnancy test 2 weeks after transfer to see if successful  First pregnancy ultrasound scan is performed 3 weeks later.

Question 34

What is intracytoplasmic sperm injection?

Answer 34

o Similar protocol to IVF o Indicated in severe MF infertility o Single sperm injected into denuded oocyte.

Question 35

Dangers of fertility treatment?

Answer 35

Ovarian hyperstimulation syndrome (OHSS) | Multiple pregnancy

Question 36

What is OHSS?

Answer 36

Iatrogenic process  Vasoactive product released from ovaries  Increased capillary permeability, fluid accumulation in the abdomen and severe dehydration due to loss of vascular fluid – LIFE THREATENING.  Young, PCOS, pregnant

Question 37

Options for fertility preservation in men?

Answer 37

• Advisable prior to any therapy that potentially affects fertility - Chemotherapy, Radiotherapy, Surgery (Testicular, Reproductive tract, Retroperitoneal nerve plexus (para-aortic node dissection)) • Postpubertal boys and adults o Sperm cryopreservation • Prepubertal boys (currently no clinically available option)

Question 38

Options for fertility preservation in women?

Answer 38

• GnRH analogues for ovarian suppression o Encouraging evidence from trials on women having chemotherapy for breast cancer o No clear evidence on other cancers – can try empirically • Oocyte / embryo cryopreservation o Reproductive autonomy vs freeze-thaw survival • Social egg freezing/ anticipation of age-related decline in fertility