infertility

Question 1

how does fertility change with age?

Answer 1

declines with age due to ovarian egg reserve declining

Question 2

what are the different steps of conception?

Answer 2

• ovulation
• sperm production
• fertilisation
• implantation

Question 3

descibe the hypothalmo-pituitary gonadal axis

Answer 3

Question 4

describe the ovulation cycle?

Answer 4

Question 5

what are the two phases of the ovarian cycle?

Answer 5

follicular phase

luteal phase

Question 6

describe the hormonal control for male reproduction?

Answer 6

Question 7

what does FSH act on in males and what effect does it have?

Answer 7

spermatogonia in seminiferous tubules of testes, causing spermatogenesis

Question 8

what does LH act on in males and what effect does it have?

Answer 8

leydig or interstitial cells of testis, causing formation of androgens (testosterone)

Question 9

natural conception relies on?

Answer 9

• functioning hormonal axis and gonads
• ovarian reserve
• regular ovulation
• normal sperm production
• fertilisation: egg and sperm interaction; patent fallopian tubes
• normal uterine cavity for implantation

Question 10

what lifestyle factors impact ferility?

Answer 10

• age
• BMI
• smoking
• alcohol
• recreational drug use
• stress

Question 11

what is inferility

Answer 11

inability to conceive over a 12 month period despite regular exposure to unprotected intercourse

Question 12

infertility is describe as being over what period?

Answer 12

> 12 months

Question 13

describe the epidemiology of inferility (% of woman affected and fraction of couples in Western world)?

Answer 13

• 10% of woman are affected

- 1/7 couples in western world are affected

Question 14

when should people be referred for infertility clinic?

Answer 14

• no conception after one year of regular unprotected intercourse

refer earlier if:

• > 35 years
• known cause for infertility

Question 15

describe the aetiology of female infertility?

Answer 15

• ovulatory dysfunction (most common)
• diminishing ovarian reserve
• endometriosis
• uterine factor
• tubal factor

Question 16

describe the aetiology of male infertility?

Answer 16

hormone problems: hormonal control

erection and ejaculation problems

• prostate surgery
• damage to nerves
• ejaculation problems
• timing of intercourse
• medication

Question 17

how is infertility investigated?

Answer 17

are eggs available?

are sperm available?

can they meet?

Question 18

what investigations are done to see if eggs are available?

Answer 18

ovarian reserve test – blood test and scan

blood tests – FSH

USS – antral follicular count

D21 serum progesterone to check if ovulation is happening

• levels > 20nmol/L show satisfactory ovulation
• couples can use LH ovulation kits or ovulation calendar themselves

Question 19

what investigations are done to see if sperm are available?

Answer 19

semen analysis

Question 20

what things are looked at in semen analysis?

Answer 20

volume - 1.5 million
total sperm number - 39 million
concentration - 15 million/ml
vitality - 58%
progressive motility - 32%
total motility - 40%
normal morphology - 4%

Question 21

what investigations are done to see if egg and sperm can meet?

Answer 21

intercourse

patent fallopian tubes

• hysterosalpingogram (HSG): no pelvic infection or gynaecological problems
• laparoscopic dye test

Question 22

describe the management for infertility?

Answer 22

egg

• optimise BMI
• healthy lifestyle
• exercise
• medication: ovulation induction
• laparoscopic ovarian drilling

sperm

• medical treatments – gonadotrophins
• surgical sperm retrieval – epididymis/testis
• donor sperm – intrauterine insemination
• ICSI (intracytoplasmic sperm injection)

tubes

• role of surgery limited to mild tubal disease
• IVF (in-vitro fertilisation)

Question 23

what medication can be given to induce ovulation?

Answer 23

• clomiphene citrate

- gonadotrophins

Question 24

what is the medical term for no sperm?

Answer 24

azoospermia

Question 25

what is IVF regulated by?

Answer 25

Human Fertilisation & Embryology Authority (HFEA) - regulating authority - licensing - inspections - forms – registration, treatment, outcome - register

Question 26

describe the process of IVF in steps?

Answer 26

If using own eggs, gonadotrophin used to induce superovulation donor eggs may be used if – older age (poor ovarian reserves), poor quality, ovarian failure, genetic cause sperm ejaculate from partner collected on the day or frozen sample from surgical retrieval or fertility preservation donor sperm can be used for single woman, same sex relationship, azoospermia, genetic cause or infection (HIV, Hep B, Hep C)

Question 27

why would donor eggs be used for IVF?

Answer 27

older age (poor ovarian reserves), poor quality, ovarian failure, genetic cause

Question 28

describe the IVF process key steps in numbers?

Answer 28

``` controlled ovarian stimulation follicular monitoring timing ovulation egg collection lab fertilisation – insemination (partners sperm produced and mixed into dish with egg) /ICSI (used in low sperm count, sperm injected into egg) – 60/70% success rate incubation/embryo development embryo transfer – done under US guidance into uterine cavity progesterone support ``` pregnancy test after 2 weeks, if positive scan at 7 weeks (US)

Question 29

What are the risks of IVF?

Answer 29

- ovarian hyper stimulation syndrome (OHSS) - multiple pregnancies - medication side effects - procedure related

Question 30

What are IVF indications other than inferility?

Answer 30

```

• Donor gametes
• Fertility preservation
• Ovarian tissue cryopreservation
• Preimplantation genetic diagnosis
• Assisted hatching
• In vitro maturation
• Surrogacy

```