Fertility

Question 1

give 5 causes of infertility

Answer 1

• Failure of sperm problem (most common)
• Ovulation problem
• Tubal problems
• Uterine problems
• Unexplained

Question 2

give 6 pieces of lifestyle advice for coupls getting pregnant

Answer 2

• 400mcg folic acid daily (woman)
• healthy BMI
• avoid smoking and excessive alcohol
• reduce stress
• aim for intercourse every 2-3
• AVOID timed intercourse

Question 3

what female hormone testing is done for fertility investigations

Answer 3

• serum LH (high may = PCOS) on day 2-5
• serum FSH (high may suggest poor ovarian reserve) on day 2-5
• progesterone on day 21 : rise = ovulation has occurred
  -anti-mullerian hormone : marker of ovarian reserve. high = good ovarian reserve
• TFT
• Prolactin if Sx of galactorrhea or amenorrhea

Question 4

what further Ix can be performed in secondary care to assess fertility

Answer 4

-USS pelvis for PCOS or uterine structural abnormalities
-Hysterosalpingogram to look at patency of fallopian tubes
-Laparoscopy and dye test for patency of fallopian tube, adhesions and endometriosis

Question 5

what is a hysterosalpingogram

Answer 5

assess shape of uterus and patency of fallopian tubes
x-ray images are taken with a contrast medium
if dye doesn’t fill one of the tubes = obstruction

Question 6

give 6 treatments options for anovulation

Answer 6

weight loss for PCOS
clomifene to stimulate ovulation
ovarian drilling in PCOS
metformin in insulin insensitivity & obesity

Question 7

what is clomifene

Answer 7

-A selective oestrogen receptor modulator (anti-oestrogen)
Stops neg feedback of oestrogen on hypothalamus
Greater GnRH release and subsequently greater FSH and LH

Question 8

how can sperm issues be managed

Answer 8

• surgical sperm retrieval if there is a blockage
• surgical correction of obstruction
• intra-uterine insemination
• intracytoplasmic sperim injection
• donor insemination

Question 9

give 3 pre testicular causes of male infertility

Answer 9

• hypothalamus or pituitary pathology
• suppression due to stress, chronic conditions or hyperprolactinaemia
• kallman syndrome

can all cause hypogonadotrophic hypogonadism (low FSH, low LH = low testosterone)

Question 10

Give 2 testicular causes of male infertility

Answer 10

1. Testicular damage : Mumps, Undescended testes, Trauma, Radiotherapy, Chemotherapy, Cancer
2. Genetic or congenital disorders : klinefelter, Y chromsome deletions, sertoli-cell only syndrome, anorchia (absent testes)

Question 11

what are the post-testicular causes of male infertility

Answer 11

• ejaculatory duct obstruction
• rertrograde ejaculation
• scarring from epididymitis
• absence of vas deferens

Question 12

give 5 Ix for male infertility

Answer 12

hormonal analysis : FSH, LH and testosterone
genetic testing
further imagining
vasography
testicular biopsy

Question 13

what are the 6 steps of IVF

Answer 13

suppressing natural menstrual cycle
ovarian stimulation
oocyte collection
insemination
embryo culture
embryo transfer

Question 14

how can the natural menstrual cycle be suppressed

Answer 14

-GnRH agonists (e.g. goserelin) : given in luteal phase. Itially stumulates pituitary to secrete large amounts of FSH and LH. There is then negative feedback suppressing natural GnRH, suppressing menstrual cycle.
-GnRH antagonist protocol (e.g. cetrorelix) : from 5-6 days of ovarian stimulation suppresses the body releasing LH and causing ovulation to occur

Question 15

What Ix are performed in primary care for infertility ?

Answer 15

• BMI - > low could indicate anovulation, high could indicate PCOS
• Chlamydia screening
• Semen analysis
• Female hormonal testing
• Rubella immunity in the mother

Question 16

what instructions are given to men prior to a semen sample and what is assessed in the sample ?

Answer 16

• Abstain from ejaculation for at least 3 days and at most 7 days
• Avoid hot baths, sauna and tight underwear during the lead up to providing a sample
• Attempt to catch the full sample
• Deliver the sample to the lab within 1 hour of ejaculation
• Keep the sample warm (e.g. in underwear) before delivery
• Assess quantity and quality of semen and sperm

Question 17

Normal sperm result s

Answer 17

• Semen volume (more than 1.5ml)
• Semen pH (greater than 7.2)
• Concentration of sperm (more than 15 million per ml)
• Total number of sperm (more than 39 million per sample)
• Motility of sperm (more than 40% of sperm are mobile)
• Vitality of sperm (more than 58% of sperm are active)
• Percentage of normal sperm (more than 4%)

Question 18

Explain the difference between IVF and IUI

Answer 18

• In vitro fertilisation = fertilising egg with a sperm in the lab efore injecting embryo into uterus
• Intrauterine insemination = injecting sperm into uterus

Question 19

how is ovarian stimulation done in IVF?

Answer 19

• Subcut injections of FSH from day 2 of cycle over 10-14 days
• When enough follicles have developed = injection of human chorionic gonadotropin hCG 36 hrs before egg collection

Question 20

4 complications of IVF

Answer 20

Failure
Multiple pregnancy
Ectopic pregnancy
Ovarian hyperstimulation syndrome

Question 21

How does OHSS present ?

Answer 21

• Early : within 7 days of hCG injection
• Late : from 10 days onwards
• Features : Abdominal pain and bloating, N&V, Diarrhoea
  Hypotension, Hypovolaemia, Ascites, Pleural effusions, Renal failure, Peritonitis from rupturing follicles releasing blood, Prothrombotic state (risk of DVT and PE)

Question 22

how is the severity of OHSS defined ?

Answer 22

• Mild: Abdominal pain and bloating
• Moderate: Nausea and vomiting with ascites seen on ultrasound
• Severe: Ascites, low urine output (oliguria), low serum albumin, high potassium and raised haematocrit (>45%)
• Critical: Tense ascites, no urine output (anuria), thromboembolism and acute respiratory distress syndrome (ARDS)

Question 23

When would progesterone be taken to check for progesterone in a woman struggling with fertility ?

Answer 23

7 days before next expected period

Question 24

Ovulation causes of infertility

Answer 24

• PCOS
• Hyperprolactinaemia
• Underweight
• Excessive exercise
• Premature ovarian insufficieny

Question 25

Non patent fallopian tubes as cause of infertility

Answer 25

Endometriosis Adhesions Infection

Question 26

If infertility is caused by hyperprolactinaemia, what other symptoms may be reported

Answer 26

Galactorrhoea Menorrhagia Bitemporal hemianopia Diplopia

Question 27

Management of hyperprolactinemia as a cause of infertility

Answer 27

Dopamine agonist (e.g. bromocriptine)