PBL 1: Subfertility

Question 1

Define subfertility

Answer 1

Inability to conceive for 12 months after commencing unprotected regular intercourse

Question 2

What types of subfertility are there?

Answer 2

Primary

Secondary

Question 3

What are causes of subfertility?

Answer 3

Pelvic inflammatory disease
Endometriosis
Fibroids
PCOS

Question 4

What are the three types of ovulatory causes?

Answer 4

T1: Hypopituitary failure -> anorexia
T2: Hypopituitary dysfunction -> PCOS, hyperprolactinaemia
T3: Ovarian Failure

Question 5

What is PSCOS characterised by?

Answer 5

Mild obesity

Question 6

What is diagnostic criteria for PSCOS?

Answer 6

Oligomenorrhea
Clinical hyperandrogenaemia
Polycystic ovaries on ultrasound

Question 7

What is cause of PSCOS?

Answer 7

Insulin resistance -> hyperinsulinaemia -> androgen production theca cells

Question 8

What is management for PSCOS if patient wishes to conceive?

Answer 8

Weight loss
Clomiphene
Surgery: ovarian drilling or wedge resection

Question 9

What is management of PSCOS if patient does not wish to conceive?

Answer 9

Low dose contraceptive pills (restore menstrual regulatory)
Metformin
Anti-androgens

Question 10

What does ovarian failure involve?

Answer 10

Persistent FSH raised

Question 11

What is management of ovarian failure

Answer 11

Donor eggs

Alternative parenting

Question 12

What are the tubdal and uterine causes of infertility?

Answer 12

Pelvis inflammatory disease
Endometriosis
Fibroids

Question 13

What is pelvis inflammatory disease

Answer 13

Severe inflammation of the peritoneal cavity caused by infection spreading from the vagina and cervix to the uterus, oviducts, ovaries and pelvis area

Question 14

How to diagnose PElvis inflammatory disease?

Answer 14

May be asymptomatic
Pelvis pain, dyspareunia, fever
Cervical excitation (painful cervix when touched)

Question 15

What are causes of pelvic infalmmatory disease?

Answer 15

STIs such as chlamydia

gonorrhoea

Question 16

How to manage pelvic inflammatory disease?

Answer 16

Antibiotics
rest
abstinence

Question 17

What is endometriosis?

Answer 17

Presence of tissue histologically like endometrium outside the uterine cavity

Question 18

How to diagnose endometriosis?

Answer 18

Pain
Dysmenorrhoea
Menorrhagia
Dyspareunia

Question 19

How to manage endometriosis?

Answer 19

NDAIDs
COPC
GnRH Agonists
Surgery

Question 20

What are fibroids?

Answer 20

Benign tumours of smooth muscle of myometrium

NOTE THE LOCATION OF FIBROIDS

Question 21

Symptoms of fibroids?

Answer 21

Heavy regular periods
Menorrhagia
Dyspareunia

Question 22

How to treat fibroids?

Answer 22

COCP
LARCs
surgical
Radiological (embolisation)
Surgery (hysterectomy)

Question 23

What are male factors?

Answer 23

Testicular
Azoospermia
Reversal of vasectomy
Ejaculatory problems
hypogonadism

Question 24

What are coital problems

Answer 24

Dyspareunia

Coital frequency <3 times a week

Question 25

What do you not offer in unexplained infertility?

Answer 25

Clomiphene as it does not increase chance of pregnancy/live birth

Question 26

After how many years do you offer IV?

Answer 26

2 years

Question 27

What drugs are linked to infertility in females?

Answer 27

Long-term NSAID use neuroleptics spironolactone depo-provera

Question 28

What drugs are linked to infertility in men?

Answer 28

Anabolic steroids | chemotherapy

Question 29

What drugs are linked to both male and female infertility?

Answer 29

Chemotherapy | Illicit drugs

Question 30

How do you diagnose infertility in female (history wise)?

Answer 30

``` Menstrual history previous pregnancies galactorrhoea hirutism previous contraceptive history ```

Question 31

What do you check for history wise in males to diagnose?

Answer 31

history of mumps orchitis occupation e.g. excessive heat abuse e.g. alcohol

Question 32

What do you examine for in female?

Answer 32

``` endocrine/systemic diseases hirsutism pelvis tumours fibroids cysts genital abnormalities ```

Question 33

What do you examine for in males?

Answer 33

endocrine/systemic diseases lack of virilisation small testicular size epididymal cysts

Question 34

When do you perform semen analysis?

Answer 34

after 3 days of abstinence | to confirm abnormality, done 3 times. each after month's interval

Question 35

What other tests can be done?

Answer 35

``` Ovulation tests basal body temperature chart pulsatile LH secretion Luteal phase plasma progesterone level tubal patency + levic normality postcoital/kremer tests ```

Question 36

How long must fertilisation occur after ovulation?

Answer 36

12-24 hours

Question 37

What do you check for in postcoital/kremer test?

Answer 37

Cervical hostility

Question 38

What do you check for in pulsatile LH secretion test?

Answer 38

Reach peak 36 hrs before ovulating | Determined in urine in simple homing testing kits

Question 39

What will luteal phase plasma progesterone level be to confirm subfertility?

Answer 39

>=30nmol/ml

Question 40

How does prempak-C mechanism of action work?

Answer 40

Includes oestrogen and progesterone

Question 41

What is it vital to ensure before treatment of subfertility?

Answer 41

Woman is immune to rubella

Question 42

How to treat ovulation failure?

Answer 42

Oral clomiphene citrate | if unsuccessful then use human menopausal gonadotrophins

Question 43

What do you monitor in treatment of female?

Answer 43

``` Transvaginal ultrasound (observe follicular) Serum oestradiol measurements to reduce risks of multiple pregnancies (ovarian hyperstimulation syndrome) ```

Question 44

What can be used 1st line for tubal subfertility?

Answer 44

Tubal microsurgery

Question 45

What is intraterine insemination

Answer 45

Sperm is separated in lab and there is removal of slower speed sperm before partner is inseminated

Question 46

When does insemination take place in IUI?

Answer 46

day 12-16

Question 47

What do you use to monitor IUI if using ovarian stimulating drugs?

Answer 47

ultrasound

Question 48

Who do you offer IUI to?

Answer 48

Ppl who can't have intercourse Required specific consideration (HIV) Same sex relationships

Question 49

How many trials do you use IUI for before IVF?

Answer 49

12 cycles

Question 50

Who do you offer IVF to?

Answer 50

Women under40 who have not conceived after 2 yrs of unprotected intercourse women 40-42 is never had IVF

Question 51

What is intracytoplasmic sperm injection

Answer 51

Single sperm injected directly into egg

Question 52

When is ICSI offered?

Answer 52

Severe deficits in sperm quality Obstructive and non obstructive azoospermia failure of IVF treatment

Question 53

What is post--code variation?

Answer 53

NHs funding for fertility treatment is very different dependent on where a person lives as the trusts make their own decisions