Infertility

Question 1

What percentage of couples suffering from infertility will conceive spontaneously or with relatively simple advice?

Answer 1

50%

Question 2

What are some reasons for the increase in incidence of infertility?

Answer 2

• Older women
• Rise in chlamydia infections
• Increase in obesity
• Increase in male factor infertility
• Increasing awareness of treatments
• Change in expectations

Question 3

What percentage of couples conceive within 6 months of trying?

Answer 3

75%

Question 4

What percentage of couples conceive within 12 months of trying?

Answer 4

90%

Question 5

What percentage of couples conceive within 24 months of trying?

Answer 5

2 years

Question 6

How long after attempted conception is IVF offered by NHS Scotland?

Answer 6

2 years

Question 7

What is infertility?

Answer 7

Failure to achieve a clinical pregnancy after 12 months or more of regular, unprotected sexual intercourse (In absence of a known reason) in a couple who have never had a child

Question 8

What is meant by primary infertility?

Answer 8

The couple has never concieved before

Question 9

What is meant by secondary infertility?

Answer 9

The couple has previously conceived, although this may not have been successful (e.g. miscarriage, ectopic pregnancy)

Question 10

What are some factors that increase fertility?

Answer 10

• Women aged under 30
• Previous pregnancy
• <3 years trying to conceive
• Intercourse around ovulation
• BMI 18.5 - 30 m/kg2
• Both partners non smokers
• Caffeine intake less than 2 cups daily
• No use of recreational drugs

Question 11

What are some causes of infertility in females?

Answer 11

• Tubal disease
• Fibroids
• Endometriosis/adenomyosis
• Weight
• Age
• Ovulatory disorders (Causing anovulatory infertility)

Question 12

What are some conditions that can cause anovulatory infertility?

Answer 12

Ovulatory disorders
Chronic renal failure
Thyroid disease
Testosterone secreting tumours
Congenital adrenal hyperplasia
Contraceptive pills (E.g. Depo-provera, Explanon, OCP)

Question 13

What is meant by tubal disease?

Answer 13

Tubal diseases are conditions affecting the fallopian tubes

Question 14

What are some clinical features of tubal disease?

Answer 14

• Abdominal or pelvis pain
• Vaginal discharge dyspareunia
• Cervical excitation menorrhagia
• Dysmenorrhoea
• Infertility
• Ectopic pregnancy

Question 15

What are the 2 types of cause of tubal disease?

Answer 15

Infective
Non-infective

Question 16

What are some infective causes of tubal disease?

Answer 16

• Pelvic inflammatory disease (Chlamydia, gonorrhoea, syphilis, TB)
• Transperitoneal spread (Appendicitis, intra-abdominal abscess)
• Infection following procedures (IUCD, hysteroscopy, HSG)

Question 17

What are some non-infective causes of tubal disease?

Answer 17

• Endometriosis
• Surgical (Sterilisation, ectopic pregnancy)
• Fibroids
• Polyps
• Congenital
• Salpingitis isthmica nodosa (Diverticulosis of fallopian tubes)

Question 18

What is endometriosis?

Answer 18

This is the presence of endometrial glands outside the uterine cavity

Question 19

What are some factors that increase risk of endometriosis?

Answer 19

Retrograde menstruation
Altered immune function
Abnormal cellular adhesion molecules
Genetic factors

Question 20

What are some symptoms of endometriosis?

Answer 20

• Dysmenorrhoea (Before menstruation)
• Dyspareunia
• Menorrhagia
• Painful defection
• Chronic pelvic pain
• Infertility

Question 21

What will investigation show on endometriosis?

Answer 21

Investigation will show a fixed and retroverted uterus with characteristic chocolate cysts on the ovaries

Question 22

What are some risk factors for male infertility?

Answer 22

Occupation
Smoking
Alcohol
Obesity

Question 23

What are some pre-testicular causes of male infertility?

Answer 23

• Hypogonadism
• Hypothyroidism
• Diabetes
• Erectile dysfunction

Question 24

What are some testicular causes of male infertility?

Answer 24

• Idiopathic
• Undescended testicles
• Urogenital infection
• Sexual factors
• Varicocele
• Torsion

Question 25

What are the 2 categories of male infertility?

Answer 25

Obstructive Non-destructive

Question 26

How will obstructive male infertility present?

Answer 26

Obstructive infertility will present with normal testicular volume, normal secondary sexual characteristics but the vas deferens may be obstructed or absent

Question 27

What are some endocrine features of obstructive male infertility?

Answer 27

- Normal LH - Normal FSH - Normal testosterone

Question 28

How will non-obstructive male infertility present?

Answer 28

Non-obstructive infertility will present with low testicular volume and reduced secondary sexual characteristics The vas deferens will be present and functional

Question 29

What are some endocrine features of non-obstructive male infertility?

Answer 29

- High LH - High FSH - Low testosterone

Question 30

What does examination of a female in infertility involve?

Answer 30

- General examination - BMI testing - Body hair distribution assessment - Pelvic examination - Assessing for pelvic tenderness and mobility

Question 31

What are some investigations required in female infertility?

Answer 31

- HCG (Pregnancy) test - Endocervical swab (For chlamydia) - Cervical smear - Blood testing (For rubella immunity) - Mid-luteal progesterone level (7 days prior to expected period - Progesterone >30 is normal) - Hysterosalpingiogram (HSG) tests tubal patency - Laparoscopy - Hysteroscopy

Question 32

What condition is shown on this hysterosalpingiogram?

Answer 32

Bilateral hydrosalpinx

Question 33

What is shown?

Answer 33

Tubal septum formation

Question 34

What is shown?

Answer 34

Tubal polyp

Question 35

What is involved in general examination of male infertility?

Answer 35

- General examination - BMI measurement - Assessment of testicular size and position - Feel for presence of penile abnormalities, vas deferens and varicoceles

Question 36

What is the initial test used in male infertility?

Answer 36

2 semen analyses, 6 weeks apart

Question 37

What are normal test results in semen analysis?

Answer 37

- Volume >1.5ml - pH 7.2 - 7.8 - Concentration >16 x 10^6 - Motility >30% - Morphology >4% - WBC < 1x10^6/ml

Question 38

What tests are carried out if semen analysis is mildly abnormal?

Answer 38

LH FSH Testosterone Prolactin Thyroid hormones

Question 39

What tests are carried out if semen analysis is severely abnormal?

Answer 39

Chromosomal analysis CF screening Testicular biopsy (may be required)

Question 40

What tests can be used in cases of male genital abnormality?

Answer 40

Scrotal ultrasound

Question 41

How often should intercourse be performed in conception?

Answer 41

Every 2-3 days, instead of timing intercourse with the menstrual cycle

Question 42

What are some management options used in infertility management?

Answer 42

Treatment of the underlying cause Vitamin supplementation Lifestyle advice Occasionally reproductive surgery

Question 43

What vitamin supplements can be used in infertility?

Answer 43

Folic acid and vitamin D are the main 2 vitamin supplements usually required

Question 44

In whom should folic acid be given to in infertility?

Answer 44

5mg OD folic acid should be given to women who are planning pregnancy or are in the early stages of pregnancy if they: - (Or partner) Have a neural tube defects - Have had a previous baby with neural tube defect - (Or partner) Have a family history of neural tube defects - Have diabetes

Question 45

What dose of folic acid is given in pregnancy in most women?

Answer 45

400ug OD is given in pregnancy and throughout the 1st 12 weeks

Question 46

What dose of vitamin D is given in pregnancy?

Answer 46

10ug OD

Question 47

What are some indications for reproductive surgery?

Answer 47

- Pelvic adhesions - Grade 1&2 endometriosis - Chocolate cysts in ovary - Tubal block - Enhancement of IVF