Infertility/subfertility

Question 1

How many couples report infertility problems?

Answer 1

1/7

Question 2

What is the definition of infertility?

Answer 2

Inability of a couple to conceive after 12 months of regular intercourse without use of contraception

Question 3

What percentage of couples in general population manage to conceive within one year if the women is under 40 and they do not use contraception and have regular intercourse?

Answer 3

80%

Question 4

80% of couples in general population will conceive within 1 year if:

Answer 4

Woman is aged under 40

They do not use contraception and have regular intercourse

Question 5

What are the main questions about why couples might not be able to conceive?

Answer 5

Are eggs available?
Is sperm available?
Can they meet?
Can embryo implant?

Question 6

What is asked about in female history re: fertility?

Answer 6

Duration of infertility
Previous contraception
Fertility in previous relationships
Previous pregnancies and complications
Menstrual history
Medical and surgical history
Sexual history
Previous investigations
Psychological assessment

Question 7

What is check in a female examination re: fetility?

Answer 7

Weight/height
BMI
Fat and hair distribution
Galactorrhoea
Abdo exam
Pelvic exam

Question 8

What can a cause of hirsutism be?

Answer 8

PCOS (excessive androgen levels)

Question 9

What is the clinical scoring system for measuring hirsutism in women?

Answer 9

Ferriman Gallwey Score

Question 10

What biochemicals are measured to check for hirsutism?

Answer 10

Testosterone
Dehydroeplandrosterone sulphate (DHEAS)
Progesterone

Question 11

What is acanthosis nigricans a sign of?

Answer 11

Androgen excess

Question 12

What are you looking for in a pelvic examination?

Answer 12

Masses
Pelvic distortion
Tenderness
Vaginal septum
Cervical abnormalities
Fibroids

Question 13

What are the 3 types of fibroid?

Answer 13

Submucous
Intramural
Subserosal

Question 14

What are the signs of fibroids?

Answer 14

Pressure symptoms
Period problems
Infertility

Question 15

What are baseline investigations in a female for infertility?

Answer 15

Rubella.immunity
Chlamydia
TSH
Mid luteal progesterone (if periods regular)
Day 1-5 FSH, LH, PRL, TSH, testosterone (periods irregular)

Question 16

What is the baseline investigation in a male for infertility?

Answer 16

Semen analysis

Question 17

What are investigations that can be done at fertility clinic?

Answer 17

Pelvic USS
Physical exam
Testing for ovulation
Semen analysis repeat
Tubal patency test

Question 18

How can ovulation be assessed?

Answer 18

Regular monthly menstrual cycles - likely ovulating
Serum progesterone blood test in mid-luteal phase of cycle (day 21) to confirm ovulation

Irregular monthly menstrual cycles - same test later
Blood test to measure serum gonadotrophins (FSH and LH)

Question 19

What is the screening for tubal occlusion in investigating infertility?

Answer 19

Hysterosalpingography (HSG)

Question 20

What is a more invasive test to check for tubal occlusion in suspected infertility?

Answer 20

Laparoscopy

Question 21

What is asked about in male history re: fertility?

Answer 21

Developmental: testicular descent, change of shaving frequency, loss of body hair
Infections: mumps, STIs
Surgical: varicocele repair, vasectomy
Previous fertility
Drugs/environmental: smoking, alcohol, anabolic steroids, chemo, radiation, drugs
Sexual history: libido, frequency of intercourse, previous fetility assessment
Chronic mental illness

Question 22

What is examined in males re: infertility?

Answer 22

Weight/height
BMI
Fat and hair distribution (hypoandrogenism)
Abdo and inguinal exam
Genital exam: epididymis, testes, gas deferens, varicocele

Question 23

What can cause epididymitis?

Answer 23

STIs:

• Chlamydia trachomatis
• Gonorrhoea

Question 24

What is a varicocele?

Answer 24

Dilatation of pampiniform plexus of the spermic veins in the scrotum

Question 25

What are signs of varicocele and presumptive infertility?

Answer 25

Low sperm concentration and abnormal

Question 26

What is one of the most common causes of primary hypogonadism with impaired spermatogenesis and testosterone deficiency?

Answer 26

Klinefelter syndrome

Question 27

What is CBAVD?

Answer 27

Congenital bilateral absence of the vas deferens

Question 28

What can cause CBAVD?

Answer 28

Cystic fibrosis mutations

Question 29

When would you refer a couple to infertility clinic?

Answer 29

``` 1 year of trying Period irregularities PMH Testicular problems Abnormal tests HIV/Hep B Anxiety Age: - <35 after 1yr - 35-45 after 6mo - >45 (little can be offered) ```

Question 30

What are the 3 classes of ovulatory disorder?

Answer 30

Group I: hypothalamic pituitary failure Group II: hypothalamic-pituitary-ovarian dysfunction Group III: ovarian failure

Question 31

What is included in Group I hypothalamic pituitary failure?

Answer 31

Hypothalamic amenorrhoea | Hypogonadotrophic hypogonadism

Question 32

How can women in Group I ovulatory disorders improve their chances of regular ovulation, conception and uncomplicated pregnancy?

Answer 32

Increasing their body weight if BMI less than 19 | Moderating exercise levels

Question 33

What can you offer women with Group I ovulation disorders to induce ovulation?

Answer 33

Gonadotrophin-releasing hormone | Gonadotrophins with LH activity

Question 34

What are signs/signs of PCOS?

Answer 34

Androgen excess Infrequent periods Polycystic ovaries

Question 35

How can you tell there is androgen excess?

Answer 35

Clinical: hirsutism Biochemical: testosterone levels

Question 36

What is the management of ovulatory disorders?

Answer 36

Treat underlying cause Weight loss/gain Ovulation induction: clomifene or gonadotrophins

Question 37

What drugs can be used to induce ovulation?

Answer 37

Clomifene Gonadotrophins GnRH

Question 38

What is the action of clomifene?

Answer 38

Binds to estrogen receptors - stimulates gonadotrophin release And Direct effect on ovaries

Question 39

How is clomifene use monitored?

Answer 39

Follicle scanning in 1st cycle | May need dose adjustment

Question 40

What are side effects of clomifene?

Answer 40

Vasomotor | Visual

Question 41

When are gonadotrophins used for ovulation?

Answer 41

No ovulation with clomifene | Ovulation but no pregnancy

Question 42

How are gonadotrophins given to induce ovulation?

Answer 42

FSH by injection

Question 43

What are hydrosalpinges?

Answer 43

The fallopian tube is blocked and fills with serous or clear fluid near the ovary

Question 44

What should women with hydrosalpinges be offered before IVF?

Answer 44

Salpingectomy

Question 45

What are options for male infertility/subfertility?

Answer 45

IVF Intra-uterine insemination Surgery: reversal vasectomy/surgical sperm retrieval Donor insemination

Question 46

What are the two types of azoospermia?

Answer 46

Testicular | Posr-testicular

Question 47

What are testicular causes of azoospermia?

Answer 47

Normagonadotrophic Hypogonadism Hypergonadotrophic

Question 48

What are post-testicular causes of azoospermia?

Answer 48

Iatrogenic Congenital Infective

Question 49

What are investigations for azoospermia?

Answer 49

History and exam FSH, LH, testosterone, karyotype, PRL CF screen

Question 50

When should you not offer ovarian stimulation agents (clomifene)?

Answer 50

Women with unexplained infertility

Question 51

How long should women with unexplained infertility try to conceive before offering IVF treatment?

Answer 51

2 years

Question 52

What is ICSI?

Answer 52

Intracytoplasmic sperm injection (ICSI) Injection of mature eggs with single sperm Incubation overnight Embryo transferred to uterine cavity

Question 53

24yr woman present with 18mo history of amenorrhoea since stopping OCP 28mo ago to try for pregnancy. BMI is 31. What is the most appropriate next step investigation?

Answer 53

Hormone profile to check SHBG, free testosterone and FSH and LH and prolactin

Question 54

24yr woman present with 18mo history of amenorrhoea since stopping OCP 28mo ago to try for pregnancy. BMI is 31. What is the most likely diagnosis? - Anorexia nervosa - Hyperprolactinaemia - Hypogonadotrophic hypogonadism - PCOS - Premature ovarian failure

Answer 54

PCOS

Question 55

Which of the following is correct with regards to PCOS? - A high FSH and LH level - Affected women are very fertiile - Affects >50% infertile pop - Metformin contraindicated - US appearance of large number of follicles arranged peripherally in the ovarian cortex of large volume ovaries

Answer 55

US appearance of large number of follicles arranged peripherally in the ovarian cortex of large volume ovaries

Question 56

28yr woman with PCOS and primary subfertility of 4yra attends fertility clinic. Her cycles are irregular and she is currently on Metformin, helping her weight control (BMI 28), she is amenorrheic. Keen to start fertility treatment. A hysterosalpingogram confirmed bilaterally patent tubes. What is most appropriate initial mangemt of her subfertilit? - Advice on weight loss and review 6mo - Intrauterine insemination for six cycles - Laparoscopic diathermy to ovaries - Ovulation induction with clomifene 50mg for 6mo - Recommend one cycle IVF treatment

Answer 56

Ovulation induction with clomifene