Infertility

Question 1

Define infertility (2)

Answer 1

Failure to establish clinical pregnancy after 12 months of regular, unprotected sex
Or caused by the impairment of persons capacity to reproduce,
Results in disability

Question 2

Name 6 prevention strategies against infertility

Answer 2

• Promote safe sex and prevent STI with screening at every visit
• maintain healthy weight - fertility decreased if BMI > 25 or <20
• avoid delaying pregnancy
• avoid smoking, drugs, alcohol
• avoid unnecessary use steroids in men
• avoid exposure to environmental toxins, pesticides, chemicals

Question 3

How long is fertilisation capacity of sperm and oocytes

Answer 3

Sperm up to 5 days in fallopian tubes
Oocyte 12-18 hours

Question 4

Name 4 broad causes of female infertility

Answer 4

• Tubal factor infertility
• endometriosis induced infertility (47%)
• uterine factor infertility: uterine leiomyomata, intrauterine adhesions, congenital uterine anomalies, isthmocele
• ovulation disorders (30%): hypogonadotropic hypogonadism, eugonadotropic hypogonadism, hypergonadotropic hypogonadism, hyper prolactinaemia, hyper and hypothyroidism

Question 5

What causes tubal factor infertility? Pathophysiology? (4)

Answer 5

STI! (Also genital tract tb, bilharzia)

Fallopian tube mucosa contains glands which produce various secretions. When occluded → secretions accumulate → hydrosalpinx.

Repeated infections may → PID → pyosalpinx

This impairs natural infertility and implantation: fluids in damaged fallopian tubes has substances toxic to blastocyst and endometrium.

Question 6

Treatment options tubal factor infertility? (2)

Answer 6

• IVF (offer salpingectomy or prox tubal occlusion to all with thick fibrotic tubes, previous tubal surgery and ultrasound visible hydrosalpinges before IVF)
• salpingectomy and tuboplasty (if can’t afford IVF)

Question 7

Mechanisms of infertility caused by endometriosis? (4)

Answer 7

• Decreased fertilisation rates
• lower implantation rates (reduced endometrial expression of implantation molecules)
• follicle depletion with ovarian endometriosis or endometriOma
• tubal damage (inflammation)

Adhesions

Question 8

Treatment options infertility caused by endometriosis? (3)

Answer 8

Severe (equally effective)

• surgical treatment
• IVF

Mild-moderate

• intrauterine insemmination

Question 9

Name and describe 4 causes uterine factor infertility

Answer 9

• Uterine fibroids: submucosal fibroids and fibroids within junctional zone between endometrial and myometrial layers only.
• Intrauterine adhesions / Asherman syndrome: present with hypomenorrhoea, infertility and or recurrent pregnancy losses. Small, distorted cavity seen on hysterosalpingogram or on saline infusion sonography. Often due to unsafe top
• congenital uterine anomalies: cause pregnany loss, abnormal foetal lie and presentation, prematurity etc
• isthmocele: common pouch-like defect in c/s scar of endometrium. Contains blood debris and mucus → post menstrual bleeding and discharge.

Question 10

Name and describe 5 ovulation disorders that cause infertility

Answer 10

• Hypogonadotropic hypogonadism: anorexia, elite athletes, chronic stress. Low fsh,llt, estradiol. BMI < 18 stops ovulation. Lifestyle intervention only.
• eugonadotropic hypogonadism: PCOS! Normal hormone profile. Rx lifestyle.
• hypergonadotropic hypogonadism: primary ovarian insufficiency. Eg spontaneous premature ovarian failure, prior chemo/radiation, previous mumps, ovarian reserve damaged by surgery. Rx donor oocyles for assisted reproduction
• hyperprolactinaemia: rx daily bromocriptine or weekly carbogoline (dopamine agonists ). Rarely transsphenoïdal surgery on pituitary
• hypo and hyperthyroid

Question 11

Name 5 treatment options female infertility

Answer 11

• Intrauterine insemination: indicated mild - moderate endometriosis and PCOS. Preferred option for same sex couples and HIV. Success rate low (<15%) so should be offered at least 3 cycles
• ovulation induction: letrozole best. Alternative = clomiphene citrate; metformin ( add to clomiphene in patients BMI >25 and in clomiphene resistance)
• IVF: indicated for blocked fallopian tubes, severe endometriosis, failed Intrauterine insemination, AMA. Success rate > 50% in young.
• laparoscopic ovarian drilling: second line. Only if booked for another procedure in theatre bc risk tissue damage and reduction in reserve.
• Gonadotrophins: second line in PCOSwho didn’t respond to first line.