Infertility

Question 1

define infertility

Answer 1

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 2

two types of infertility

Answer 2

primary= couple who have never conceived
secondary= previously conceived but not successful e.g. miscarriage or ectopic pregnancy

Question 3

factors that increase the chance of conception

Answer 3

under 30
previous pregnancy
less than 3 years trying to conceive
sex around ovulation
healthy BMI
non-smoker (both)
caffeine intake less than 2 cups of coffee daily
no illicit drugs

Question 4

physiological causes of anovulatory infertility

Answer 4

before puberty
pregnancy
lactation
menopause

Question 5

gynaecological causes of anovulatory infertility

Answer 5

• hypothalamic= anorexia/bulimia (low FSH, LH and oestradiol), excessive exercise
• pituitary= hyperprolactinaemia, tumours and Sheehan syndrome
• Ovarian= PCOS, premature ovarian failure

Question 6

other causes of anovulatory infertility

Answer 6

systemic= chronic renal failure
endocrine= testosterone secreting tumours, CAH, hypothyroid
drugs= depoprovera, explain and OCP

Question 7

infective causes of tubal disease

Answer 7

PID (chlamydia, gonorrhoea, anaerobes, syphilis, TB)
transperitoneal spread (appendicitis, intra-abdominal abscess)
after procedure (IUCD insert, hysteroscopy and HSG)

Question 8

non-infective causes of tubal disease

Answer 8

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

Question 9

define hydrosalpinx

Answer 9

condition where the fallopian tube is blocked and filled with serous/clear fluid near the ovary

Question 10

presentation of hydrosalpinx

Answer 10

abdominal/pelvic pain
febrile
vaginal discharge dyspareunia
cervical excitation menorrhagia
dysmenorrhoea
infertility
ectopic pregnancy

Question 11

what is the management in tubal disease

Answer 11

surgical

Question 12

proximal obstruction surgery in tubal disease

Answer 12

salpinography plus tubal catheterisation or hysteroscopic tubal cannulation

Question 13

management of hydrosalpinges

Answer 13

salpingectomy by laparoscopy

Question 14

what does success of the operation depend on?

Answer 14

amount of healthy tube

presence of adhesions

Question 15

define endometriosis

Answer 15

presence of endometrial glands outside uterine cavity

Question 16

causes of endometriosis

Answer 16

genetic
retrograde menstruation
altered immune function
abnormal cellular adhesion molecules

Question 17

presentation of endometriosis

Answer 17

dysmenorrhoea (classically before menstruation)
dyspareunia
menorrhagia
painful defaecation
chronic pelvic pain

Question 18

diagnosis of endometriosis

Answer 18

chocolate cysts on ovary

Question 19

management of endometriosis

Answer 19

removal of cysts can be ablation, resection, adhesiolysis and cystectomy

Question 20

types of fibroids

Answer 20

pedunculated
sub mucous (hyperoscopically)
intramural
subserous (no management)

Question 21

investigations for infertility

Answer 21

• history, examination, BMI, genital/pelvic examination

- tubal patency

Question 22

how to assess tubal patency?

Answer 22

laparascopy

hysterosalpingogram (use if laparoscopy contraindicated in obesity, previous pelvic surgery or Crohn’s)

Question 23

when should laparoscopy be used?

Answer 23

possible PID
previous pathology (ectopic pregnancy, ruptured appendix and endometriosis) or previous abnormal HSG

Question 24

when should hysteroscopy be used?

Answer 24

known/suspected endometrial pathology e.g. uterine septum (metroplasty), adhesions/polyps

Question 25

when should USS be used

Answer 25

abnormality on pelvic examination

Question 26

endocrine investigations in infertility

Answer 26

anovulatory/infrequent periods= HCG, prolactin, TSH, testosterone, SHBG, LH, FSH and oestradiol hirsute= testosterone and SHBG amenorrhoea= endocrine and chromosome analysis

Question 27

non-obstructive causes of male infertility

Answer 27

``` 47XXY chemotherapy radiotherapy undescended testes idiopathic ```

Question 28

presentation of non-obstructive male infertility

Answer 28

low testicular volume | reduced secondary sexual characteristics with vas deferens present

Question 29

diagnosis of non-obstructive male infertility (biochemically)

Answer 29

high LH/FSH | low testosterone

Question 30

causes of obstructive male infertility

Answer 30

congenital (CF) infection vasectomy

Question 31

presentation of obstructive male infertility

Answer 31

normal testicular volume normal secondary sexual characteristics vas deferens may be absent

Question 32

diagnosis of obstructive male infertility (biochemically)

Answer 32

normal LH, FSH and testosterone

Question 33

investigations for male infertility

Answer 33

``` semen analysis (twice over 6 weeks apart) hormones chromosome analysis CF screening testicular biopsy scrotal USS ```

Question 34

who should have 5mg a day of folic acid if they are planning/in early stages of pregnancy?

Answer 34

diabetics they or their partner has a neural tube defect previous baby with neural tube defects FH of neural tube defects