Infertility

Question 1

Definition

Answer 1

Failure to conceive within 12 months given adequate opportunity

Question 2

Rates of conception at 12 months and 24 month

Answer 2

90% at 12 months

95% at 2 years

Question 3

Female causes

Answer 3

1. Amenorrhea/ovulatory dysfunction
Hypothalamus/pituitary
PCOS
Premature ovarian failure
Uterine outflow disorders
2. Tubal defect
3. Endometriosis
4. Other

Question 4

Male causes

Answer 4

1. Hypogonadism->primary and secondary
2. Cryptocrchidism
3. XXY
4. Disordered sperm transport
5. GU surgery

Question 5

History

Answer 5

1. Duration of trying
2. Frequency of intercourse and technique->coitus every other day mid cycle
3. Contraceptive history
4. PID, endometriosis
5. Age of partners
6. Menstrual history: premenstrual symptoms, regularity, ovulation pain, vaginal secretions (thin=E, thick=P)
7. FHx->PCOS, fragile X
8. PMHx: surgery, infections, pain, liver/renal/heart/thyroid
9. Pap smears, LLETZ (cervical incompetence)
10. Medication, alcohol, smoking, drugs
11. Previous pregnancies->miscarriages

Question 6

Examination

Answer 6

1. General
\++Male pattern hair, acne, obesity, acanthosis nigricanc
Adipose->+adrenal, PCOS, diabetes
Galactorrhea (+prolactin)
Thyroid examination
2. Genital
Pelvic organs->fibroids, cysts, endometriosis, PID
Vagina->structural, muscle spasm

Question 7

Investigations in women

Answer 7

1. Ovulatory
TSH->both hyper/hypothyroid can disrupt ovulation
Prolactin->elevates interferes
Androgens (androgen secreting tumors), sex hormone binding globulin
Day 21 serum Progesterone
LH, FSH->if elevated menopause/resistant ovarian
2. Tubal damage->done by specialist infertility gynaecologist
Sonohysteroscopy
Hysterosalpingogram
Laparoscopy
3. Other
Lipids
Glucose
FBC
VZ, rubella screen
Pelvic USS

Question 8

PCOS: LH, FSH, SHBG

Answer 8

LH day 2-5 cycle
If +LH, normal FSH,
\+testosterone, low SHBG=
PCOS
Early follicular FSH/estradiol
- may respond to IVF

Question 9

Investigations in men

Answer 9

Semen analysis->must not ejaculate for 2 days, semen produced by masturbation, all require (if abnormal) repetition at 3 months (duration of spermatogenesis)
TSH
Prolactin
Karyotype
Lipids
Glucose

Question 10

Treatment in men

Answer 10

Treat hormonal deficiency
Donor insemination
IVF
Intracytoplasmic sperm injection

Question 11

Management in women

Answer 11

1. Referral to fertility specialists
2. Clomiphene cutrate->5 days in early proliferative
   Anti-estrogen at pituitary= ++FSH->+follicle growth and ovulation
   70-80% fertility in 12 cycles

Question 12

Side effects of clomiphene citrate

Answer 12

Hot flushes
Nausea
HeadA
\+Menstrual pain
\+Chance of multiple pregnancies

Question 13

Complication of IVF

Answer 13

1. Perinatal morb/mortality
2. Multiples
3. Ovarian hyperstimulation
   Mild= bloating, pain, ascites
   Moderate= distension, NV, ascites, hematology and blood chemistry altered
   Severe= ++Ascites, requiring hospitalisation, pleural effusion, prekidney failure, anuria

Question 14

Mechanisms of ascites, in ovarian hyperstimulation

Answer 14

1. Ascites
   extravasation and increased leakage of
   protein-rich fluid from the intravascular space into the
   abdominal cavity, owing to an osmolar differential.

Question 15

Pain and renal impairment in ovarian hyperstimulation

Answer 15

1. Pain
Torsion
Hemorrhage
Rupture
2. Renal
Extravasation of fluid

Question 16

Hypercoagulable in ovarian hyperstimulation

Answer 16

Hemoconcentration and hypovolemia from third spacing and fluid shift
Also +estrogen