Infertility

Question 1

Define infertility

Answer 1

• Failure to conceive after frequent unprotected sexual intercourse for one or two years

Question 2

What is primary infertility?

Answer 2

• Never been pregnant

Question 3

What is secondary infertility?

Answer 3

• Previous pregnancy (including ectopic and terminations) but struggling to conceive again

Question 4

What is subfertility?

Answer 4

• Generally describes any form of reduced fertility that results in a prolonged duration of unwanted lack of conception

Question 5

What are the causes of infertility?

Answer 5

• Unidentifiable in 25%
• Male causes 30%
• Ovulatory causes 25%
• Tubal factors 20%
• Uterine and peritoneal disorders 10%
• Other (gamete/embryo defects, coital problems, concurrent health problems)

Question 6

Outline the pre-testicular causes of male infertility?

Answer 6

1. Endocrine:
   - Hypogonadotropic hypogonadism
   - Hyperprolactinaemia
   - Hypothyroidism
   - Diabetes
2. Coital problems
   - Ejaculatory disorders
   - Erectile dysfunction
3. General health/systemic illness

Question 7

Outline the testicular causes of male infertility

Answer 7

1. Genetic
   - Klinefelter syndrome
   - Y chromosome deletion
   - Immotile cilia syndrome
2. Congenital (cryptorchidism)
3. Infective (STIs)
4. Antispermatogenic agents
   - Heat
   - Irradiation
   - Drugs
   - Chemotherapy
5. Vascular
   - Torsion
   - Varicocoele

Question 8

Outline the post-testicular causes of male infertility

Answer 8

1. Obstructive
   - Congenital (CBAVD/CUAVD)
   - Acquired (infective/vasectomy)
2. Coital problems
   - Sexual dysfunction
   - Hypospadias

Question 9

Outline Group 1 ovulatory disorders

Answer 9

• Hypothalamic-Pituitary failure - 10%
• Hypothalamic amenorrhoea
• Hypogonadotropic hypogonadism

Question 10

Outline Group 2 ovulatory disorders

Answer 10

• Hypothalamic-Pituitary-Ovarian Dysfunction - 85%
• PCOS
• Hyperprolactinaemic amenorrhoea

Question 11

Outline Group 3 ovarian failure

Answer 11

• Ovarian failure - 5%
• Premature ovarian failure
• Congenital e.g. Turner’s syndrome (45X0)

Question 12

How do uterine and peritoneal disorders lead to infertility?

Answer 12

• Physical reasons why implantation fails
• Uterine fibroids
• Conditions causing scarring/adhesions e.g. endometriosis, PID, previous surgery, Asherman syndrome
• Mullerian developmental abnormalities

Question 13

What causes tubal damage?

Answer 13

• Conditions affecting fallopian tube causing disrupted transport of ovum
• Endometriosis
• Ectopic pregnancy
• Pelvic surgery
• PID
• Mullerian developmental anomaly - agenesis

Question 14

What questions do we need to ask males presenting with infertility?

Answer 14

• Testicular trauma/disorders
• Ejaculatory/erectile dysfunction

Question 15

What questions do we need to ask females presenting with infertility?

Answer 15

• Age
• Obstetric/Gynae history (cycle and cervical)
• Smear, procedures
• Menstrual disorders

Question 16

What history do we need to obtain from males and females presenting with infertility?

Answer 16

• Full medical history
• Surgical history
• Social history - alcohol, smoking, occupation, previous children/pregnancies
• Sexual health history
• Sexual dysfunction

Question 17

How do we examine males for infertility?

Answer 17

• Not usually required
• Examine penis for structural abnormalities
• Scrotal exam
• Secondary sexual characteristics

Question 18

How do we examine females for infertility?

Answer 18

• BMI
• Secondary sexual characteristics e.g. hirsutism, acne
• Abdominal/pelvic/vaginal exam for masses, tenderness, infection, uterus size/position, vaginismus

Question 19

What advice should be given to patients suffering with infertility?

Answer 19

• Smoking cessation
• Reduce alcohol intake
• Lifestyle changes - stress
• Regular intercourse
• Weight loss
• Reassurance

Question 20

What investigations should be done in males with infertility?

Answer 20

• Semen analysis - sperm count, motility, liquification studies
• Bloods - LH/FSH, testosterone
• STI screen
• Ultrasound scan testes
• Karyotyping

Question 21

What investigations should be done in females with infertility?

Answer 21

• FSH/LH
• Mid-luteal phase progesterone (day 21/28)
• TFTs, prolactin levels, androgens
• STI screen
• Pelvic USS
• Hysterosalpingogram
• Laparoscopy

Question 22

How do we refer infertile patients to secondary care?

Answer 22

• Consider referral if history, exam, and investigations are normal in both partners and not conceived after 1 year
• Consider early referral in women >36 years/after 6/12 or there’s a known cause
• Offer counselling throughout process

Question 23

How do we manage patients with infertility?

Answer 23

• Medical treatment - ovulation induction (Clomifene)
• Surgical treatment - fix tubal occlusions e.g. laparoscopy
• Assisted reproductive technology = means of conception other than normal coitus e.g. intrauterine insemination, IVF etc.