Subfertility

Question 1

Infertility

Answer 1

Disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse

Question 2

Primary infertility

Answer 2

Woman unable to ever bear a child, either due to inability to become pregnant or inability to carry a pregnancy to a live birth
–> miscarriages, ectopics, abortions and stillborns

Question 3

Secondary infertility

Answer 3

Woman unable to bear a child, either due to inability to become pregnant or inability to carry a pregnancy to live birth following either a previous pregnancy or a previous ability to carry a pregnancy to a live birth

Question 4

Subfertility Causes

Answer 4

Ovulatory Disorders (25%)
Tubal Damage (20%)
Uterine/peritoneal disorders (10%)
Male factors (30%)
Unexplained (25%)

Question 5

Ovulatory causes

Answer 5

Type 1- Hypopituitary failure (anorexia)
Type 2- Hypopituitary Dysfunction e.g. PCOS, hyperprolactinaemia
Type 3- Ovarian Failure

Question 6

PCOS

Answer 6

2 out of3 of:
Clinical hyperandrogenaemia
Oligomenorrhea (less than 6-9 periods/year)
Polycystic ovaries on ultrasound

Question 7

PCOS signs

Answer 7

Menstrual disturbance (oligomenorrhea, amenorrhea, DUB)
Infertility hirsutism
Acne
Male pattern hair loss
Central obesity
Acanthosis nigricans

Question 8

PCOS medical signs

Answer 8

Raised LH with normal FSH

Raised testosterone

Question 9

PCOS exclusions

Answer 9

Thyroid dysfunction
Congenital adrenal hyperplasia
Hyperprolactinaemia
Androgen-secreting tumours

Question 10

PCOS associated metabolic abnormalities

Answer 10

Abnormal serum lipid concentrations

Insulin resistance

Question 11

Tubal + Uterine causes of Infertility

Answer 11

Pelvic inflammatory disease
Previous tubal surgery
Endometriosis (uterine + tubal)
Fibroids (uterine)
Cervical mucus defect

Question 12

Pelvic Inflammatory disease- Acute

Answer 12

May be asymptomatic
Pelvic pain
Deep dyspareunia
Malaise
Fever
Purulent vaginal discharge

Question 13

PID Examination

Answer 13

Cervical excitation
Adnexal tenderness
Discharge
pyrexia

Question 14

PID Investigation

Answer 14

ECS- MC+S plus chlamydia, FBC, raised ESR

Question 15

PID Management

Answer 15

Antibiotics
Rest
Abstinence

Question 16

Chronic PID

Answer 16

From inadequately treated acute PID

Question 17

Endometriosis

Answer 17

Presence of tissue histologically similar to endometrium outside uterine cavity + myometrium
Most commonly found in pelvis

Question 18

Endometriosis RFs

Answer 18

Age
FH
Frequent cycles

Question 19

Endometriosis symptoms

Answer 19

Pain
Dysmenorrhoea
Menorrhagia
Dyspareunia

Question 20

Endometriosis exam

Answer 20

Pelvic tenderness or mass

Fixed uterus

Question 21

Endometriosis management

Answer 21

NSAIDs
Norethisterone
Danazol
GnRH agonists
Surgery

Question 22

Fibroids

Answer 22

Uterine leiomyoma

Benign tumours of smooth muscle of myometrium

Question 23

Fibroids types

Answer 23

Subserosal
Intramural
Pedunculated
Submucosal

Question 24

Fibroids symptoms

Answer 24

Heavy, regular periods

Question 25

Fibroids management

Answer 25

Tran acid COCP/LARCs Surgical

Question 26

Male causes infertility

Answer 26

``` Testicular- infection, cancer, surgical, congenital, undescended testes, trauma Azoospermia Reversal vasectomy Ejaculatory problems Hypogonadism ```

Question 27

Drugs linked to infertility- WOMEN

Answer 27

``` Long term NSAID use Chemotherapy Neuroleptics Spironolactone Depo-provera ```

Question 28

Drugs linked to infertility- MEN

Answer 28

Sulfasalazine Anabolic steroids Chemotherapy Chinese herbs for improving sperm count + motility

Question 29

Drugs linked to infertility- BOTH

Answer 29

Marijuana Coke Other illicit drugs

Question 30

Investigations by GP prior to infertility referral

Answer 30

``` Full sexual/contraception/fertility history PCOS screen- day 21 progesterone, LH, FSH, serum testosterone, glucose FBC TSH Vit D HbA1c HIV Hep Rubella STI screen ```

Question 31

Sperm count ranges

Answer 31

Volume (ml) LRL 1.5ml Progressive motility (%) LRL 32% Morphology (%) LRL 4% normal

Question 32

Assessing tubal function

Answer 32

HSG | HyCoSy

Question 33

Assess uterine function

Answer 33

Laparoscopy

Question 34

Ovulatory disorder- Type 1 hypopituitary failure Management

Answer 34

Increase weight Decreases exercise Pulsatile GnRH

Question 35

Ovulatory disorder- Type 2 PCOS Management

Answer 35

Wight loss to BMI 30 or below Clomiphene or Metformin Laparoscopic ovarian drilling Gn therapy

Question 36

Ovulatory disorder- Type 2 Hyperprolactinaemia Management

Answer 36

Bromocriptine

Question 37

Ovulatory disorder- Type 3 Ovarian Failure management

Answer 37

Donor eggs

Question 38

Tubal/uterine infertility Management

Answer 38

Laparoscopic tubal surgery Surgery prior to IVF to attempt fibroid/endometriosis clearance Adhesiolysis Endo treatment

Question 39

Male infertility treatment

Answer 39

Treat infections Hypogonadism- consider gonadotrophins Erectile dysfunction- DM control, depression support

Question 40

Clomiphene

Answer 40

Medication used to treat infertility in women who do not ovulate Includes those with PCOS

Question 41

Intrauterine insemination (IUI)

Answer 41

Sperm is separated in lab Slower sperm removed Partner inseminated --> those who can't have vaginal intercourse 15.8% success under 35

Question 42

IVF

Answer 42

Fertilisation of egg outside body | 32.2% live births under 35

Question 43

IVF better if

Answer 43

``` Age Less cycles Previous pregnancies BMI 19-30 No smoking No caffeine ```

Question 44

Ovarian hyperstimulation syndrome

Answer 44

Consequence of drugs used to stimulate ovarian function Gonadotrophin or clomiphene REFER

Question 45

Intracytoplasmic Sperm Injection

Answer 45

Embryologist selects single sperm to be injected directly into egg --> severe deficits in semen quality, obstructive + non-obstructive azoospermia

Question 46

IVF risks

Answer 46

Small increased risk of borderline ovarian tumours

Question 47

Cancer + preserving fertility

Answer 47

Cryopreservation before chemo