PBL 1 - Subfertility

Question 1

What is subfertility

Answer 1

When a couple fails to conceive in one year of regular, unprotected sexual intercourse

Question 2

Difference between primary and secondary infertility

Answer 2

Primary - unable to become pregnant

Secondary - previously pregnant but now cannot

Question 3

Infertility definition

Answer 3

When a couple is unable to conceive a child after more than 12 months of regular, unprotected sexual intercourse

Question 4

What is prempak

Answer 4

Form of hormone replacement therapy - two types of tablets, one is oestrogen and the other is norgestrel which contains progesterone.

Question 5

Female hormone cycle

Answer 5

GnRH from hypothalamus –> Anterior pituitary -> Releases FSH and LH –> Stimulates ovarian follicles –> follicles produce oestrogen –> negative feedback at low concentration

Question 6

What causes ovulation of oocyte

Answer 6

• After a certain threshold, oestrogen becomes a positive feedback loop –> drastically increase LH causing ovulation of oocyte

Question 7

What does corpus luteum release

Answer 7

Progesterone, inhibin and oestrogen –> inhibits FSH and GnRH and LH

Question 8

Why does the HRT contain both FSH and LH

Answer 8

reduced FSH and LH so egg cannot be released/fertilised

Question 9

Causes of fertility problems in females

Answer 9

1) Ovulatory disorders - 25%
2) Tubal damage - 20%
3) Uterine/peritoneal - 10%
4) Unexplained - 25%

Question 10

3 ovulatory disorders

Answer 10

PCOS, adenoma, hyperprolactinaemia

Hypopituitary failure and dysfunction

Question 11

Type 1 ovulatory disorder

Answer 11

Hypopituitary failure (Anorexia nervosa, adenoma)

Question 12

Type 2 ovulatory disorder

Answer 12

Hypopituitary dysfunction (PCOS, hyperprolactinaemia)

Question 13

Symptoms of PCOS

Answer 13

Acne
Hirsutism - male pattern hair growth 
Oligomenorrhoea, amenorrhoea, DUb (menstrual distrubances)
Infertility 
Central obesity 
Ancanthosis nigricans

Question 14

How to diagnose PCOS

Answer 14

Rotterdam criteria (Need 2+)
Clinical hyperandrogenaemia
Oligomenorrhoea (6 to 9 in a year)
Polycystic ovaries on ultrasound + anovulation

Question 15

How can weight gain worsen PCOS

Answer 15

Weight gain –>hyperinsulinemia + insulin resistance –> stimulation of theca cells to produce more LH than FSH due to increasing pulsatile GnRH

Question 16

Treatment of PCOS

Answer 16

To concieve = Lose weight, Clomiphene, metformin, ovarian drilling
Not concieve - low dose COC, anti-androgens, metformin

Question 17

MoA clomiphene

Answer 17

Induce ovulation

Question 18

Example of anti androgen

Answer 18

Cyproterone acetate

Question 19

Type 3 ovulatory problem

Answer 19

Ovulatory failure (old age)

Question 20

Differentials PCOS

Answer 20

1) androgen secreting tumour 2) hyperprolactinaemia 3) Hypothyroidism

Question 21

Tubal and uterine disease

Answer 21

Pelvic inflammatory disease
Endometriosis
Fibroids
Cervical mucus defects

Question 22

What is pelvic inflammatory disease

Answer 22

 Inflammation of the peritoneal cavity caused by infection spreading from vagina + cervix –> uterus, oviducts, ovaries and pelvic area

Question 23

Causes of pelvic inflammatory disease

Answer 23

Chlamydia trachomatis, Neisseria gonorrhoeae

Question 24

Tx of PID

Answer 24

Broad spectrum antibiotics

Question 25

Male problems with infertility

Answer 25

``` o Disorders of sperm production or transport o Testicular e.g. infection, cancer, o Azoospermia (no sperm) o Ineffective reversal of vasectomy o Hypogonadism e.g. Klinefelter ```

Question 26

How to do semen analysis

Answer 26

after 3 days abstinence, 2-5ml is normal, repeated 3 times each after a month o Look at morphology, density and motility

Question 27

Ovulation tests

Answer 27

o Basal body temperature – rise of 1 degree for 14 days from mid cycle indicates ovulation (not used) o Pulsatile LH – peaks 36hrs before ovulation, can be detected in urine using home testing o Postcoital/Kremer test – test for cervical hostility o Plasma progesterone in Luteal phase = ovulation o Tubal function- HyCoSy, USS, Hysteroscopy o Uterine function- laparoscopy

Question 28

Female history

Answer 28

menstrual history, previous pregnancies, hirsutism, contraceptive history

Question 29

Male history

Answer 29

mumps orchitis, occupation (heat, radiation, toxic chemicals), cigarette, alcohol

Question 30

Male examination

Answer 30

virilisation, small testicular size, epidydimal cysts and varicoceles

Question 31

Female examination

Answer 31

signs of endocrine/systemic disease, pelvic tumours (Fibroids, ovarian cysts, genital abnormalities)

Question 32

Tx of tubal subfertility

Answer 32

Tubal microsurgery, IVF-ET

Question 33

Intrauterine insemination

Answer 33

o Sperm is separated in lab, removal of slower speed sperm, before partner is inseminated o Offer to:  People who are unable to have vaginal intercourse (disability).  Requiring specific consideration (eg sperm wash in HIV pos men)  Same-sex relationships o 12 cycles in total before offer IVF

Question 34

In vitro fertilisation

Answer 34

o Fertilisation of an egg (or eggs) outside the body.

Question 35

Who to offer IVF to

Answer 35

 Women under 40 who have not conceived after 2 years of unprotected intercourse or 12 cycles of artificial insemination (6 IUI). • Offer 3 full cycles (cycle being 1 ovarian stimulation and transfer of resultant fresh/frozen embryos).  Offer one cycle to 40-42 year old women if: • 2 years unprotected intercourse • 12 cycles AI (6 or more IUI). • Never previously had IVF • No evidence of low ovarian reserve.

Question 36

Intracytoplasmic Sperm Injection

Answer 36

 Embryologist selects a single sperm to be injected directly into an egg, instead of fertilisation taking place in a dish where many sperm are placed near an egg.

Question 37

When to give ICSI

Answer 37

• Severe deficits in semen quality • Obstructive azoospermia • Non-obstructive azoospermia • Couple in whom previous IVF treatment cycle has resulted in failed or very poor fertilisation  ICSI improves fertilisation rates compared to IVF alone, but once fertilisation taken place, the pregnancy rate is no better than with IVF.

Question 38

What is postcode lottery

Answer 38

o In the NHS the Clinical Commissioning Groups (CCGs)/primary care trust make their own decisions about funding towards certain treatments in the area they are in charge of o Some areas of UK women are not getting 3 full cycles of IVF which is written in NICE guidelines in 2013

Question 39

What is the effect of pituitary adenoma

Answer 39

• In pituitary adenoma, there is the stalk compression effect which causes the excess production of prolactin. High levels of prolactin can cause low levels of oestrogen which will disrupt the menstrual cycles.