Infertility

Question 1

what is a basic definition of infertility

Answer 1

the inability of a couple to conceive within 12 months without the use of contraception

Question 2

what % of couples are able to conceive without problem

Answer 2

for those <40yrs:
80% will conceive within 1 year of trying
half of those who do not in the first year will in the second

Question 3

how many couples experience problems with fertility

Answer 3

1 in 7

Question 4

when should infertility be investigated

Answer 4

if after 1 year of trying there is no pregnancy

Question 5

when should you potentially investigate fertility sooner

Answer 5

if there's a problem e.g.
period irregularity
past medical history
testicular problems
abnormal test results
HIV/Hep B
anxiety

age
<36 yrs after 1 year
35-45 years after 6 months
>45 yrs little can be offered

Question 6

what are the three main queries when it comes to infertility

Answer 6

are there eggs available?
is there sperm available?
can they meet?

Question 7

what should be covered in a female history for infertility

Answer 7

duration of infertility 
previous contraception
fertility in previous relationships
previous pregnancies/complications
menstrual history
medical/surgical history
sexual history
previous investigations
psychological assessment

Question 8

what should be covered in a female examination for infertility

Answer 8

weight
height
BMI (kg/m2)
fat and hair distribution
galactorrhoea
abdominal examinaton
pelvic examination

Question 9

what are the implications of a higher BMI >30 on fertility/pregnancy

Answer 9

higher miscarriage rate
lower success of fertility treatment
higher medical complications e.g. HBP, diabetes

Question 10

what does your BMI need to be to qualify for NHS fertility treatment

Answer 10

<30

Question 11

what initial tests should be done for women first presenting with infertility problems

Answer 11

prolactin levels - prolactinaemia - if >1000 assess pituitary gland

androgen levels

• testosterone (T)
• androstendione
• dehydroepiandrosterone (DHA)
• dehydroepiandrosterone sulphate (DHAS)
• 17-OH progesterone
• Sex hormone binding globulin (SHBG)

Question 12

how can hirsutism be measured clinically

Answer 12

look for hirsutism

ferriman gallwey score - from hair distribution on:
upper lips, chin, anterior chest, inner thigh, back

Question 13

how is the ferriman gallwey score interpreted

Answer 13

Score <8 – no hirsutism
8-16 – mild
17-25 - moderate
>25 – severe

Question 14

what are clinical signs of androgen excess

Answer 14

hirsutism
galactorrhoea
acanthosis nigricans

Question 15

what should be looked for in a pelvic exam

Answer 15

masses/fibroids
pelvic distortion
fixed retroversion
tenderness
cervical abnormality
vaginal septum

Question 16

what are the complications of fibroids

Answer 16

pressure symptoms
period problems
infertility

Question 17

what are the different kinds of fibroids

Answer 17

subserosal - outwith the lining of the muscles and uterine cavity - pressure symptoms, press on bladder, pain

intramural - if >1/2cm can interfere with implantation

submucosal - can interfere with implantation

Question 18

what should be covered in a male history for infertility

Answer 18

Previous fertility
Medical history (mumps, testicular descent)
Surgical history
Occupational history
Sexual history (STD)
Previous investigations and treatment (varicocoele repair, vasectomy)
loss of body hair/less frequent shaving (less testosterone)

Question 19

what should be covered in a male examination for infertility

Answer 19

weight
height
BMI (kg/m2)
fat and hair distribution (hypoandrogenism)
abdominal and inguinal examination
genital examination

Question 20

how can the male partners BMI affect fertility

Answer 20

high BMI can have a negative influence of spermatogenesis

Question 21

what can examination of the epididymis show

Answer 21

epididymitis

STDs - chlamydia, gonorrhoea, NSTD

Question 22

what can examination of testicular size show

Answer 22

klinefelter syndrome

hyperspermia

Question 23

what can examination of the vas deferens show

Answer 23

possible CF - mutations and congenital bilateral absence of the vas deferens

NB if azoospermatic - indication to test for CF

Question 24

what can examination of the testes show

Answer 24

testicular tumours

testicular maldescent

Question 25

what is varicocoele and where is it more common

Answer 25

abnormla dilatio anf torsion of the veins in the scrotum | - more common on the left, anatomical drainage different as the they drain to the left renal vein instead of the IVC

Question 26

what can examination of the penis show

Answer 26

hypospadias

Question 27

how do you test for the availability of eggs

Answer 27

test serum progesterone in the mid-luteal phase of the cycle - day 21-28 to confirm ovulation if they have regular menstrual cycles if irregular cycles - blood tests to measure serum gonadotrophins follicle stimulating hormone (FSH) and luteinising hormone (LH)

Question 28

how do you test for the availability of sperm

Answer 28

computerised semen analysis

Question 29

``` according to WHO what are the reference vakues of: semen volume sperm concetration total sperm number progressive motility total motility morphologically normal ```

Answer 29

``` 1.5ml 15 million/ml 39 million 32% 40% 4% ```

Question 30

what are the baseline investigations for a female partner investigating infertility

Answer 30

rubella immunity chlamydia TSH if periods regular - mid-luteal progesterone (7 days prior to expected period) if periods irregular - day 1-5 FSH, LH, PRL, TSH, testosterone

Question 31

what are the baseline investigation for a male partner investigating infertility

Answer 31

semen analysis

Question 32

what investigations can be done at the fertility clinical

Answer 32

``` pelvic ultrasounds physical exam further investigations semen analysis repeat if required tubal patency test ```

Question 33

what is a HyCoSy and what is it used for

Answer 33

hysterosalpingo-contrast-sonography small catheter though cervix then dye injected through looks for patent tubes

Question 34

what is laparoscopy used for

Answer 34

can assess tubal potency diagnostic and therapautic to treat endometriosis preferred for women with a higher tubal factor

Question 35

what are the riss of laparotomy

Answer 35

risk of injury to bowel, bladder, ureter, thromboembolism

Question 36

what is the difference between primary and secondary infertility

Answer 36

primary is couples who are struggling to conceive after 1 year with no previous pregnancies secondary is couples who are struggling to convince after 1 year with at least one previous pregnancy i.e. were able to conceive before but not unable to

Question 37

from most common to least common, what are the causes of primary infertility

Answer 37

ovulation problems male - sperm problems unexplained tubal

Question 38

from most common to least common, what are the causes of secondary infertility

Answer 38

tubal ovulation problems unexplained male - sperm problems

Question 39

what is polycystic ovary syndrome

Answer 39

set of symptoms due to elevated androgens in females

Question 40

how can polycystic ovary syndrome be diagnosed

Answer 40

must beet 2 of the 3 criteria: 1. androgen excess (clinical hirsutism, biochemical testosterone) 2. infrequent periods (anovulation) 3. polycystic ovaries (seen on underground

Question 41

what defines a polycystic ovary

Answer 41

more than 12 follicles in one ovary

Question 42

what are the three groups of causes for ovulatory disorders

Answer 42

1. hypothalamic pituitary failure 2. hypo-pituitary-ovarian failure 3. ovarian failure

Question 43

what is the treatment for ovulatory disorders

Answer 43

treat the underlying cause weight loss/gain (BMI >18and <30) ovulation induction

Question 44

what are the three drugs used for ovulation induction

Answer 44

clomiphene (first line) gonadotrophins GnRH

Question 45

what is clomiphene and how is it given

Answer 45

selective oestrogen receptor modulator given 50mg-150mg day 2-6 of the cycle if amenorrhoea - progestogen priming NB does usually kept as low as possible to encourage only mono follicular development (higher % of conception)

Question 46

how and why is clomiphene monitored

Answer 46

follicle scanning occurs in the 1st cycle needed as 15% require a dose adjustment

Question 47

what are the side effects of clomiphene

Answer 47

vasomotor | visual

Question 48

how long can clomiphene be given for

Answer 48

6 cycles

Question 49

when might gonadotrophin therapy be used

Answer 49

when no ovulation with clomiphene or ovulation but no pregnancy

Question 50

how is gonadotrophin therapy given

Answer 50

FSH injection up to 3-6 cycles

Question 51

what can be done if there is a tubal factor or endometriosis affecting fertility

Answer 51

some surgical or medical treatment for endometriosis and fibroids consider IVF

Question 52

what should a women with hydrasalpinges be offered before IVF and why

Answer 52

salpingectomy - fluid filled blocked tubes may cause further problems such as ectopic pregnancy

Question 53

what treatment for infertility can males use

Answer 53

``` urologist appointment if appropriate IVF/ICSI intra-uterine insemination surgery (vasectomy reversal, surgical sperm retrieval) donor insemination ```

Question 54

what is azoospermia

Answer 54

when semen contains no sperm

Question 55

what are the types of azoospermia

Answer 55

testicular - normogonadotrophic - hypogonadotrophic - hypergonadotrophic post-testicular - iatrogenic - congenital - infective

Question 56

what are the investigations for azoospermia

Answer 56

history examination FSH, LH, testosterone, karyotype, PRL CF screen

Question 57

what is a possible treatment for azoospermia

Answer 57

surgical sperm retrieval - micro-epididymal sperm aspiration - testicular sperm extraction

Question 58

what are some options for sexual problems that lead to infertility

Answer 58

psychosexual counselling - onward referral artificial insemination - times at home, intra-uterine at clinic

Question 59

what is the best course of action in treating unexplained infertility

Answer 59

IVF | don't offer clomiphene