T2 L7 Causes and treatment of subfertility

Question 1

What are the requirements for conception?

Answer 1

Progressively motile normal sperm that are capable of reaching and fertilising oocyte
Timely release of competent oocyte
Free passage for sperm to reach oocyte and for embryo to reach uterus
Mature endometrium that allows implantation

Question 2

What is the definition of infertility?

Answer 2

Inability to conceive after 2 years of frequent, unprotected intercourse
Period of time people have been trying to conceive without success after which formal investigation is justified and possible treatment implemented

Question 3

What is the cumulative probability of pregnancy after 1 year?

Answer 3

84%

Question 4

What is the cumulative probability of pregnancy after 2 years?

Answer 4

92%

Question 5

What is the cumulative probability of pregnancy after 3 years?

Answer 5

93%

Question 6

How many couples will have a problem conceiving?

Answer 6

1 in 6

Question 7

What is the causes of infertility?

Answer 7

Unexplained - 30%
Ovulatory - 27%
Male factor - 19%
Tubal - 14%
Endometriosis - 5%
Other factors - 5%

Question 8

Why does women’s fertility decline with age?

Answer 8

Decline in oocyte number and quality rather than uterine receptivity

Question 9

What are the indications for early referral / investigations in females?

Answer 9

Aged over 35 years
Amenorrhoea / oligomenorrhoea
Previous abdominal / pelvic surgery
Previous PID / STD
Abnormal pelvic examination

Question 10

What are the indications for early referral / investigations in males?

Answer 10

Previous genital pathology - history of testicular maldescent surgery, infection or trauma
Previous STD
Significant systemic illness
Abnormal genital examination

Question 11

Describe the results of a normal semen analysis

Answer 11

Count > 15x10^6/ml
Motility >40%
Morphology >4%
Volume 1.5-6mls

Question 12

What are the causes of abnormal semen analysis?

Answer 12

No reason in 50%
Primary testicular failure is commonest cause for oligo/azoospermia
Obstructive or non-obstructive azoospermia
Y chromosome micro deletion and cystic fibrosis if sperm count <5 million

Question 13

Describe a female assessment

Answer 13

Screen for chlamydia and rubella
Ovarian reserve
- early follicular phase hormone level
- AMH
- AFD
Ovulation test
Tubal test

Question 14

What is anti-mullarian hormone (AMH)?

Answer 14

Produced by granulose cells of pre-antral and small antral stages
Levels of AMH are constant through monthly but decline with age
Higher AMH levels predict a good response
Lower AMH levels predict a poor response

Question 15

How can women monitor their ovulation?

Answer 15

Basal body temperature
Ovulation detection kits
Cervical mucous pattern
Follicular tracking or mid-literal phase P4

Question 16

What does the result of a mid-luteal P4 need to be for evidence of ovulation?

Answer 16

> 30nmol/L

Question 17

What levels should be tested in oligo/amenorrhoea?

Answer 17

FSH / LH
E2
Prolactin
TFT
Androgens
SHBG

Question 18

What is the commonest cause of a loss of tubal potency?

Answer 18

Pelvic inflammatory disease secondary to chlamydia

Question 19

What is the risk of tubal damage after 1 episode of pelvic infection?

Answer 19

12%

Question 20

What is the risk of tubal damage after 2 episodes of pelvic infection?

Answer 20

23%

Question 21

What is the risk of tubal damage after 3 episodes of pelvic infection?

Answer 21

54%

Question 22

What are some other causes of tubal disease?

Answer 22

Septic abortion
Ruptured appendix
Pelvic surgery
Ectopic pregnancy

Question 23

What is a hysterosalpingogram?

Answer 23

Procedure using X-ray to look at Fallopian tubes and uterus

Question 24

When should a hysterosalpinogram be done?

Answer 24

2-5 days after menstruation

Question 25

What are the advantages of a hysterosalpingogram?

Answer 25

Relatively safe
Ease of use
Delineation of uterine cavity and Fallopian tubes

Question 26

What are the disadvantages of a hysterosalpingogram?

Answer 26

Inability to assess pelvic peritoneum

Question 27

What is a hysterosalpingo-contrast-ultrasonography?

Answer 27

Assess fallopian tubes
Similar to HSG
No radiation

Question 28

Describe the benefits and risks of using laparoscopy and dye for investigations

Answer 28

Invasive procedure with risks of visceral injury to the patient
More sensitive and specific
Chance to diagnose and treat endometriosis and adhesions

Question 29

What can be used to induce ovulation in women with polycystic ovaries?

Answer 29

Clomid (clomifene citrate)

FSH injections for resistant PCO of hypogonadotrophic hypogonadism

Question 30

What are the indications for IUI treatment?

Answer 30

Unexplained
Mild male factor
Mild endometriosis

Question 31

What is the benefits of IUI treatment?

Answer 31

Less stress
Less invasive
Less tech
Cheap

Question 32

What is the success rate of IUI treatment?

Answer 32

10% per cycle

Question 33

What are the NICE guidelines for IUI treatment?

Answer 33

Don’t offer IUI for couples with unexplained infertility
IUI for single women, same sex couple or heterosexual couple who have problems with intercourse
IVF for couples with unexplained infertility

Question 34

What is IVF used for?

Answer 34

Tubal damage
Low sperm quality
Unexplained infertility
Low ovarian reserve

Question 35

What are the steps of IVF?

Answer 35

Controlled ovarian hyperstimulation
Egg collection
IVF
ICSI
Embryo development
Embryo transfer

Question 36

What is the success rate of IVF?

Answer 36

Depends on female partner’s age
Varies from one unit to another
National average is 30-35% for those below 35 years old