Subfertility

Question 1

Which cells secrete AMH?

Answer 1

Granulosa cells

Question 2

What proportion of anovulatory infertility is caused by PCOS?

Answer 2

> 80-90%

Question 3

What is the main mechanism by which hyperprolactinaemia causes 2dry amenorrhoea?

Answer 3

Inhibition of LH pulsatility

Question 4

What is the test for biochemical detection of hyperandrogenism?

Answer 4

Free Androgen Index

Question 5

What proportion of women with PCOS are overweight/obese?

Answer 5

40-50%

Question 6

What is the estimated prevalence of endometriosis in infertile women?

Answer 6

50%

Question 7

What is the prevalence of endometriosis in women of reproductive age?

Answer 7

2-10%

Question 8

What endometrial thickness should be achieved prior to frozen embryo transfer?

Answer 8

5mm

Question 9

Which contraception is most associated with delay in return of fertility?

Answer 9

Depoprovera

Up to 1 year

Question 10

What percentage of >35yo will take longer than a year to conceive?

Answer 10

30%

Question 11

Normal semen volume?

Answer 11

1.5 ml

Question 12

Normal sperm concentration?

Answer 12

15 million/ml

Question 13

Normal total number of sperm in ejaculate?

Answer 13

39 million per ejaculate

Question 14

Normal total motility?

Answer 14

40%

Question 15

Normal sperm forms?

Answer 15

4%

Question 16

What outcomes favour letrozole over clomiphene?

Answer 16

Higher live birth rate
Lower multiple pregnancy rate
Lower incidence of OHSS

Question 17

How does letrozole work as ovulation inductor?

Answer 17

Competitively and reversibly binds to haem component of CYP450 unit to reduce oestrogen production (selective E-receptor modulator)

Does not inhibit production of mineralocorticoids/corticosteroids

Question 18

What is the NICE guidance for treatment of Group 2 anovulatory infertility?

Answer 18

Clomiphene for 6/12

Lap ovarian drilling or clomiphene + metformin or gonadotropins

Question 19

What is the treatment for Group 1 anovulatory subfertility?

Answer 19

Optimise BMI (>19)
Pulsatile GnRH or gonadotrophins with LH activity

Question 20

What is the chance that laparoscopy confirms findings of tubal occlusion at HSG?

Answer 20

35%

Question 21

What is the treatment for male infertility secondary to Kallman’s?

Answer 21

Gonadotrophins or pulsatile GnRH pump

Question 22

What percentage of male infertility is due to post-testicular causes?

Answer 22

40%

Question 23

What is the average pregnancy rate with ICSI?

Answer 23

33%

Question 24

What percentage of women with recurrent miscarriage have antiphospholipid antibodies?
What is the background population risk?

Answer 24

15%

<2%

Question 25

What is the live birth rate in women with recurrent miscarriage associated with antiphospholipid antibodies with no intervention?

Answer 25

10%

Question 26

What are the main causes of infertility in the UK (and percentages)?

Answer 26

``` Unexplained - 25% Ovulatory - 25% Tubal - 20% Male - 30% Uterine or peritoneal - 10% 40% - disorders in both female and male ```

Question 27

What are the Rotterdam criteria?

Answer 27

1. Polycystic ovaries (>=12 peripheral follicles or volume >10cm3) 2. Oligo- or anovulation 3. Clinical and or biochemical evidence of hyperandrogenism

Question 28

What are the recommended screening tests for PCOS?

Answer 28

TSH PRL Free Androgen Index (testosterone and SHBG) If testosterone >5 - 17hydroxyprogesterone

Question 29

What measures predict high response to gonadotrophins in IVF?

Answer 29

Total antral follicle count >16 AMH >25 FSH <4

Question 30

What measures predict low response to gonadotrophins in IVF?

Answer 30

Total antral follicle count <4 AMH 5.4 FSH >8.9

Question 31

What percentage of tubal factor infertility is due to proximal disease? What is the most common cause?

Answer 31

15% Salpingitis isthmica nodosa

Question 32

What are the criteria for negligible transmission rates of HIV (ie when can normal sexual intercourse take place in men with HIV) where male is HIV positive

Answer 32

Man compliant with HAART Viral load <50 for more than 6/12 No other infections Unprotected intercourse is limited to time of ovulation If met sperm washing doesn't reduce chance of transmission

Question 33

What percentage of male factor infertility is secondary to hypogonadotrophic hypogonadism?

Answer 33

<1%

Question 34

Which circulating androgens can activate receptors?

Answer 34

DHT Testosterone NOT DHEAS

Question 35

How is testosterone metabolised and excreted?

Answer 35

In the liver into androsterone and etiocholanolone, conjugated, and excreted as 17-ketosteroids in the urine

Question 36

What metabolic problems are there in CAH?

Answer 36

Deficiency of synthesis of cortisol | Most common - deficiency of 21 hydroxylase activity (90-95%)

Question 37

What is the incidence of raised prolactin in infertile but ovulatory women?

Answer 37

3.8-11.5%

Question 38

What are the surgical indications for prolactinomas? How are prolactinomas treated in pregnancy?

Answer 38

1. Failure of medical therapy 2. Expanding lesion with neurological or ophthalmological deficits not responding to med therapy 3. Pituitary apoplexy (potentially life threatening haemorrhage/infarction) 8.5% of macroprolactinomas may need surgery in pregnancy - continue medical treatment (usually stops in early pregnancy in microprolactinomas

Question 39

What are the applications of AMH in fertility practice?

Answer 39

1. Predicting over-response and OHSS and altering stimulation protocols accordingly 2. Predicting poor response to stimulation and altering protocols accordingly to optimise oocyte yield 3. Diagnositc marker in PCOS (high levels associated with high androgens and insulin insensitivity) 4. Counselling re: poor response to avoid disappointment

Question 40

Male factor alone contributes what percentage of infertile couples?

Answer 40

30%

Question 41

What percentage of infertile couples have both male and female factor infertility?

Answer 41

40%

Question 42

What proportion of men with low sperm quality have no cause found?

Answer 42

50%

Question 43

What is the role of FSH in sperm production and which cells respond to it?

Answer 43

Increases spermatogonial number and matures to spermatocytes | Binds to Sertoli cells

Question 44

What is the role of LH in sperm production and which cells respond to it?

Answer 44

Necessary for testosterone production by Leydig cells | Essential role in spermatid maturation

Question 45

How long is spermatogenesis?

Answer 45

3 months

Question 46

What type of male infertility is characterised by decreased FSH, LH and testosteone?

Answer 46

Pretesticular - hypogonadotrophic hypogonadism

Question 47

What type of male infertility is characterised by elevated FSH and LH, low testosterone, with non-obstructive azoospermia?

Answer 47

Testicular failure - hypergonadotrophic hypogonadism Can have isolated FSH rise with normal LH and testosterone - isolated spermatogenic failure without Leydig cell damage

Question 48

What is the prevalence of varicocele in men with normal and abnormal semen?

Answer 48

11.7% and 25.4%

Question 49

What type of male infertility is characterised by normal FSH and LH with evidence of complete spermatogenesis at biopsy?

Answer 49

Post-testicular

Question 50

What number of men with varicocele have a concurrent renal abnormality?

Answer 50

30%

Question 51

What are the indications for IUI?

Answer 51

1. Mild male factor infertility 2. Immunologic infertility 3. Mechanical problems of sperm delivery (Up to 6 cycles recommended by NICE)

Question 52

What are the indications for ICSI?

Answer 52

1. Uncorrectable severe male factor infertility | 2. Fertilisation failure in previous IVF cycle

Question 53

What are pregnancy rates per embryo transfer following ICSI?

Answer 53

33%

Question 54

How much less is the chance of pregnancy with a man >40yo vs >35yo?

Answer 54

50%

Question 55

What is the rate of twin pregnancy following single and double embryo transfer?

Answer 55

Single - 2% | Double - 25-30%

Question 56

What is the lifetime incidence of infertility?

Answer 56

17% (1 in 6 couples)

Question 57

At what stage of the menstrual cycle should HSG be performed?

Answer 57

Day 7 - 12 Sens: 53% Spec: 87% 1-3% risk pelvic infection

Question 58

What is HyCoSy?

Answer 58

Hysterosalpingo contrast sonography water soluble contrast TVUS Avoids radiation exposure

Question 59

What is the risk of perforation and ectopic pregnancy with tubal catheterisation?

Answer 59

Perf - 2% | Ectopic - 3%

Question 60

What is transvaginal hydrolaparoscopy (THL)?

Answer 60

0.4-0.6L fluid into posterior fornix Small diameter endoscope Can visualise POD, adnexa, tubes and perform small procedures e.g. ovarian drilling under LA as OP Risk of bowel perf 0.61%

Question 61

What is the difference between salpingoscopy and falloposcopy?

Answer 61

Salpingoscopy is the endoscopic visualisation of the endosalpinx of the tubal infundibulum and ampulla at laparoscopy and/or THL, whereas falloposcopy is the endoscopic visualisation of the whole endosalpinx at hysteroscopy

Question 62

What is fertiloscopy?

Answer 62

Fertiloscopy is an outpatient technique that combines | hysteroscopy, THL and salpingoscopy

Question 63

what is the best assay for measuring chlamydia trachomatis antibodies?

Answer 63

Micro-immune fluorescence (MIF)

Question 64

How many cases of tubal infertility are due to proximal disease?

Answer 64

15%

Question 65

What is salpingitis isthmica nodosa (SIN)?

Answer 65

- Most common cause proximal tubal infertility - Inflammatory aetiology associated with infective PID stigmata - Endosalpingeal diverticula encased in myosalpingeal hypertrophy and fibrosis resulting in a firm proximal tubular nodule which can be seen on laparoscopic examination - Can be mimicked by endo

Question 66

By how much do ongoing pregnany rates increase following salpingectomy for hydrosalpinx?

Answer 66

x2

Question 67

What are good prognostic factors for successful reversal of sterilisation?

Answer 67

Age <35 | Residual length >4cm

Question 68

What % of women presenting with subfertility are hyperthyroid?

Answer 68

2. 3% | 1. 5% general population