Infertility

Question 1

How common is infertility?

Answer 1

Affects 1 in 7 couples

Question 2

What are the common causes of infertility? (broad)

Answer 2

Male factors - 30%
Unexplained - 20%
Ovulation failure - 20%
Tubual damage - 15%
Other - 15%

Question 3

What are the two key basic investigations to identify infertility?

Answer 3

Semen analysis in males
Serum progesterone 7 days prior to expected next period (day 21), (as released by corpus luteum after ovulation)

Question 4

How should the levels of serum progesterone at day 21 be interpreted for ferility?

Answer 4

<16nmol/L repeat is low refer to specialist
16-30 nmol/L repeat
>30 nmol/L indicates ovulation

Question 5

What key counselling points should be given to couples trying to conceive?

Answer 5

Folic acid supplements at least 3 months before conception
Aim for BMI 20-25
Regular sexual intercourse every 2-3 days
Smoking/drinking advice.

Question 6

What is classified as an assisted reproductive technology?

Answer 6

Techniques and procedures to achieve pregnancy:
- Intrauterine insemination
- In vitro fertilisation
- Intra-cytoplasmic sperm injection
- donor insemination
- egg donarion
- pre-gestation testing
- surrogacy

Question 7

What is intrauterine insemination?

Answer 7

Also = artificial insemination
Sperm introduced into uterus at ovulation.
Ovulation may be natural or stimulated
Good in cervical scarring, difficulties with penetrave sex, poor sperm motility.

Question 8

What is meant by in vitro fertilisation?

Answer 8

Stimulating egg production, then collecting and fertilsing with harvested sperm in vitro.
Traditional -> sperm must penetrate egg itself
Intra-cytoplasmic sperm injection -> sperm inserted into egg cytoplasm by micropipette, useful in low sperm mobility or difficult zona pellucida (prev frozen egg)

Question 9

What is pre-implantation genetic diagnosis?

Answer 9

IVF screening of embryos for over 600 genetic disorders before implantation
Includes: alpha thalassaemia, Huntingtons disease, early-onset dementia etc

Question 10

In surrogacy who is the legal parent of the child?

Answer 10

The woman giving birth

Question 11

Define sub-fertility.

Answer 11

A general reduction in fertility, resulting in a prolonged, unwanted period of non-conception
May not require complex specialist treatment but may have increased time to become pregnant spontaneously.

Question 12

Define infertility.

Answer 12

A disease of the reproductive system, affecting either men or women, characterized by the failure to achieve a pregnancy after 12 months (or 6 months if the woman is over 35) of regular, unprotected intercourse.

Question 13

What are the risk factors for infertility?

Answer 13

Age (F>35yrs)
Previous STI/PID
Lifestyle - psychological stress, smoking, alcohol, recreational drugs
Obesity
Physiological stress
Previous pelvic surgery -> salpingetomy etc

Question 14

What are the different potential categories of infertility in males?

Answer 14

Failure in sperm quality/quantity
Testicular failure
Obstruction
Ejaculation/erectile disorder (mechanical problems)

Question 15

What are the different types of ovulatory failure in women?

Answer 15

Type 1 - Hypothalamic pituitary failure - failure to produce GnRH, FSH and LH - Kallmann syndrome, functional amenorrhoea (anorexia) -
Type 2 - HPO axis dysfunction - PCOS
Type 3 - Ovarian failure - premature menopause
Type 4 - Endocrine/systemic - hypothyroidism, Sheehans syndrome, adrenal disorder, stress

Question 16

What are some examples of tubal causes of infertility?

Answer 16

PID
Endometriosis

Question 17

What are some examples of uterine/cervical causes of infertility?

Answer 17

Endometriosis
Surgery
Cervical mucus dysfunction
Fibroids
Asherman syndrome

Question 18

What drugs can cause infertility in females?

Answer 18

NSAIDs - inhibits PG -> inhibits follicle rupture
COXi
Spironolactone -> reduced androgen production
Chemotherapy - premature ovarian failure
Neuroleptic drugs - tetrogenic
Recreational (marijuna and cocaine)

Question 19

What are the different causes of male infertlity?

Answer 19

Unknown
Testicular - varicocele, malignancy, orchitis, trauma etc
Semen -> See card
Obstruction -> vas deferens (congenital, CF, surgical, prostatic cyst, epididymal infection)
Coital -> retrograde ejaculation, anejaculation, hypospadias

Question 20

What drugs can cause anejaculation in males?

Answer 20

Anti-depressants (SSRIs)
Alpha blockers

Question 21

What drugs can cause infertility in males?

Answer 21

Sulfazalazine - reversible
Anabolic steroids
Chemo ->
Herbal remedies

Question 22

What individuals should be referred for infertility treatment?

Answer 22

Any couple trying with regular unprotected sexual intercourse for more than 1yrs
Female 35yrs or older for 6months, or known cause of infertility or history of predisposing factors
Immediate referall in females 40yrs or older

Question 23

What investigations are typically done for male infertility initially?

Answer 23

STI screen
Semen analysis

Question 24

What is oligospermia and azoospermia?

Answer 24

Oligo = low = <15milllion per ml
Azoo = no = confirm in 2 seperate samples

Question 25

Define teratospermia

Answer 25

Abnormal sperm shape and structure

Question 26

Define asthenosperma

Answer 26

Poor mobility or sperm

Question 27

What initial investigations should be done for female infertility?

Answer 27

STI screen (particularly chlamydia) Mid-luteal progesterone FSH+LH Thyroid function tests Infection screen: BBV, Rubella

Question 28

What imaging studies may be done for female infertility?

Answer 28

Hysterosalpingography - x-ray and contrast to view the internal uterus and fallopian tubes

Question 29

How can you test for ovarian reserve?

Answer 29

Day 3: Anti-mullerian hormone (decrease with infertility as released by maturing follicles), FSH (increase with infertility) US: Antral follicle count and volume

Question 30

What imaging studies may be done in male infertility?

Answer 30

Testicular US and biopsy

Question 31

What drugs can be given to help improve fertility?

Answer 31

Clomiphene -> Selective oestrogen receptor modulator, partial agonist, blocks negative feedback of endogenous oestorgen -> inc GN release Gonadotropins Pulsatile GnRH Dopamine agonists -> correcting hyperprolactinemia

Question 32

What are some complications of assisted reproduction techniques?

Answer 32

Ovarian Hyperstimulation syndrome Multiple pregnancy Ectopic pregnancy Pelvic infection Emotional burden Psychological impacts

Question 33

What is ovarian hyperstimulation syndrome?

Answer 33

IVF stimulates VEGF release from granulosa cells Inc vascular permeability -> intravascular to extravascular space Oedema, ascities and hypovolemia hCG injection 36hrs before oocyte collection triggers the release of VEGF. Can also activate RAAS causing high renin.

Question 34

What are the risk factors for ovarian hyperstimulation syndrome during IVF?

Answer 34

Younger age Lower BMI Raised Anti-mullerian hormone higher antral follicle count POCS Raised oestrogen levels during ovarian stimulation

Question 35

What are the key features of ovarian hyperstimulation syndrome?

Answer 35

Abdo pain and bloating Nausea and vomitting Diarrhoea Hypotension Ascities Pleural effusions Renal effusions Renal failure Peritonitis from rupturing follicles releasing blood Prothrombotic state (risk of DVT and PE)

Question 36

Is a sperm analysis comes back as abnormal, after how long should a repeat test be done?

Answer 36

3 months