Infertility

Question 1

When should a couple be investigated for infertility?

Answer 1

• after trying to conceive without success for 12 months

OR

• failure to conceive after 6 months in women > 35

time is precious > 35 as ovarian stores are likely to be already reduced

Question 2

What are the 5 possible causes of infertility?

Answer 2

1. sperm problems
2. ovulation problems
3. tubal problems
4. uterine problems
5. unexplained

the causes are a mixture of male + female in 40% cases

Question 3

What general advice is given to couples trying to conceive?

Answer 3

• take 400mcg folic acid every day
• aim for intercourse every 2-3 days
• aim for a healthy BMI
• reduce stress (affects libido + relationship)
• avoid timing intercourse
• reduce/avoid smoking / alcohol

timing intercourse to conincide with ovulation is not necessary + can lead to increased stress in the relationship

Question 4

What initial investigations are performed in primary care?

Answer 4

• chlamydia screening
• BMI calculation
• semen analysis
• female hormone testing
• Rubella immunity in the mother

low BMI could indicate anovulation and high could indicate PCOS

Question 5

What are the 3 tests performed in female hormone testing?

Answer 5

• serum LH and FSH on day 2-5 of the cycle
• serum progesterone on day 21 (or 7 days from the end of the cycle if not 28 days)
• anti-Mullerian hormone

Question 6

What other female hormone tests may be done if indicated?

Answer 6

• thyroid function tests (if suggestive symptoms)
• prolactin if symptoms of galactorrhoea or amenorrhoea

hyperprolactinaemia can cause anovulation

Question 7

What may a high serum FSH indicate?

Answer 7

poor ovarian reserve

• the number of follicles the woman has left in her ovaries is low
• the pituitary gland is producing extra FSH to stimulate follicular development

Question 8

What may a high serum LH indicate?

Answer 8

PCOS

Question 9

What may a high serum progesterone indicate?

Answer 9

• a high progesterone on day 21 indicates that ovulation has occurred
• the corpus luteum has formed and is secreting progesterone

Question 10

What does a high anti-Mullerian hormone indicate?

Answer 10

good ovarian reserve

• this is secreted by the granulosa cells in the follicles
• it falls as the eggs are depleted
• it is the most accurate marker of ovarian reserve and can be measured at any time in the cycle

Question 11

What further investigations may be performed in secondary care?

Answer 11

pelvic US:

• looks for polycystic ovaries or other structural abnormalities

hysterosalpingogram:

• looks for patency of fallopian tubes

laparoscopy + dye test:

• looks for patency of fallopian tubes, adhesions + endometriosis

Question 12

What is assessed on a hysterosalpingogram?

Answer 12

• assesses the shape of the uterus

AND

• the patency of the fallopian tubes
• it has a therapeutic benefit with the rate of conception increasing after the scan

Question 13

What procedure can be performed at the same time as hysterosalpingotomy?

Answer 13

tubal cannulation

• this involves opening up a blocked fallopian tube under XR guidance

Question 14

How is a hysterosalpingogram performed?

Answer 14

• a catheter is inserted into the cervix
• a contrast medium is injected through the catheter to fill the uterine cavity + fallopian tubes
• XR images are taken
• if one of the tubes does not fill with dye, this indicates that it is blocked

Question 15

What should be performed prior to a hysterosalpingogram?

Answer 15

screening for chlamydia + gonorrhoea

Question 16

What medication may be given prior to a hysterosalpingogram?

Answer 16

prophylactic antibiotics

• there is a risk of infection with the procedure
• abx given to patients with dilated tubes or history of pelvic infection

Question 17

What is involved in a laparoscopy + dye test?

Answer 17

• during the procedure, dye is injected into the uterus
• it should be seen entering the fallopian tubes and spilling out the ends
• absence of this pattern suggests tubal obstruction
• endometriosis + pelvic adhesions can also be assessed / treated

Question 18

What are the 6 management options for anovulation causing infertility?

Answer 18

• weight loss (for PCOS)
• clomifene (stimulates ovulation)
• letrozole (alternative to clomifene)
• gonadotropins (used in women resistant to clomifene)
• ovarian drilling (used in PCOS)
• metformin if there is obesity / insulin insensitivity

Question 19

When is clomifene given?

Answer 19

days 2 - 6 of the menstrual cycle

Question 20

How does clomifene work?

Answer 20

• it is an anti-oestrogen
• it stops the negative feeback of oestrogen on the hypothalamus
• this results in a greater release of GnRH
• and a subsequent greater release of FSH + LH

Question 21

What is involved in ovarian drilling?

Answer 21

• laparoscopy is used to puncture multiple holes in the ovaries
• this involves diathermy or laser therapy
• this can improve the hormonal profile + result in regular ovulation

Question 22

What are the options for women with tubal factors affecting fertility?

Answer 22

• tubal cannulation during hysterosalpingogram
• laparoscopy to remove adhesions / endometriosis
• IVF

Question 23

What is involved in the management of uterine factors affecting fertility?

Answer 23

surgery to correct polyps, adhesions or structural abnormalities

Question 24

What are the options for management of sperm problems?

Answer 24

• surgical sperm retrieval
• surgical correction of an obstruction in the vas deferens
• intra-uterine insemination
• intracytoplasmic sperm injection (ICSI)
• donor insemination with sperm from a donor

Question 25

What is surgical sperm retrieval and when is it performed?

Answer 25

* used when a **blockage in the vas deferens** is preventing sperm from reaching ejaculated semen * a needle + syringe is used to **collect sperm from the epididymis** through the scrotum

Question 26

What is intra-uterine insemination?

Answer 26

* collection and separation of **high quality sperm** * the high quality sperm are injected **directly into the uterus** ## Footnote it is not known whether this is any better than normal intercourse

Question 27

What is intracytoplasmic sperm injection?

Answer 27

* sperm are **injected directly** into the **cytoplasm** of an egg * these fertilised eggs become embryos that are **injected into the uterus**

Question 28

When is ISCI a good option?

Answer 28

* sperm motility issues * very low sperm count