Infertility

Question 1

What are the male and female causes of infertility, and why?

Answer 1

Male

1. Androgen insufficiency (low testosterone) –> Hypo gonadism:

Primary vs Seconday (Hypothalmic/ Pituitary Dysfunction).

2. Seminiferous Tubule Dysfunction (ie, Chromosome Y abnormalities) - most common.
3. Post-teste dysfunction. Ie - Prostate hyperplasia, loss of vas deferens (CF), infection, trauma.

Female

1. Ovarian dysfunction
   - PCOS
   - Hypogonadotropic anovulation –> ovarian failure –> decreased ooctye quality and quantity.

Primary: premature ovarian failure.

Secondary: hypothalmic/ pituitary dysfunction.

2. Tubal dysfunction:
   - Infection (chlamydia)
   - Any external inflammation - appendicitis, diverticulitis –> tubal damage.
3. Uterine

Congenital: Uterine didelphys, bicornuate, unicornuate uterus (due to Mullerian duct fusion failure).

Acquired:

Fibroids (tubal obstruction, implantation issues).

Endometritis: especially post D+C (Ashermans Syndrome).

4. Cervix
   - infections/ surgeries: disrupt mucous glands of cx –> failure of sperm capacitation.
5. Extra-anatomical
   - Endometriosis - obstruction of the tubes, cytokines: toxic to sperm/embryo.
   - Pelvic adhesions (PID).

Question 2

What are the primary RF for infertility in males and females and why?

Answer 2

- Smoking:

damage to cilia (fallopian tubes + sperm motility) + accelerated menopause.

- Advanced age (>35)

Decreased quality + quantity : sperm /oocytes

- STI history

Scarring of fallopian tubes = tubal occlusion (also vas deferens).

- Weight (too little, too much)

- Steroid use

Question 3

What history and exam is done on a female complaining of infertility?

Answer 3

History:

PMH

• Menstrual (irregular, length+strength, colour, pain, full menstrual history, pre-menstrual history)
• Gyn (infections, pelvic surgeries, papsmear hx, ectopics, dysparaunia).
• Sexual history: number of partners, first sexually active, contraception.
• Obstetric

Medications

• radiation therapy
• cytotoxic chemotherapy
• drugs causing hyperprolactinemia (atypicals)

Family history

• infertility, birth defects, developmental problems

Social

• Smoking, exercise, drug, alcohol, eating.
• Systems review: Antiphospholipid syndrome, SLE, diabetes, thyroid, hirsutism, galactorrhea.

Exam:

• Abdo
• PV
• cervical smear
• swabs.

Question 4

What history and exam is done on a male who is complaining of infertility?

Answer 4

History:

PMH

• Surgeries (vasectomy, trauma to genital/pelvic region, orchiectomy).
• Infections

. mumps orchitis

. Sinopulmonary sx

. STIs

. Genitourinary infections

Developmental history

History of testosterone-sx (voice drop, testes drop, chest hair, rate of shaving).

Developmental history (Kleinfelters).

Medications

Anything that can affect fertility

• anabolic steroids
• radiation therapy
• cytotoxic chemotherapy
• drugs causing hyperprolactinemia (atypicals)

Family Hx

CF, Kleinfelters (??).

Social

smoking

drinking

diet

steroid use.

Systems review

• urinary symptoms.

Physical exam:

General, DRE, scrotal assessment (testes, vas, variocele).

Question 5

What investigations are done on males and females whom who suspect infertility?

Answer 5

FEMALES:

1. Imaging: Transvaginal US

+ Laparoscopy: gold standard assessment for pelvic abnormality + tubal patency.

2. Bloods
   - FSH, LH, androgens
   - Assessment of Ovarian reserve.
   - TSH
   - PRL
   - Luteal E2/p4
   - BSL
   - LFTs
   - Coags, factor 5 leiden, vWD
   - Anticardiolipin antibodies, ANA
3. Genetic tests.
   - Karyotyping

MALES

1. Semen analysis (morphology, vitality, motility).

• seminal fructose
• anti-sperm antibodies.
  2. Bloods
• FSH, LH
• PRL
• Testosterone
  3. Imaging
• scrotal/prostatic US
  4. Genetic tests
• karyotyping
• CFTR gene
• sex chromosome abnormalities
• microdeletions: Y chromosome

Question 6

What is the management of subfertility in males and females?

Answer 6

All except PCOS:
1st line: controlled ovarian stimulation - clomiphine citrate.

2nd line: IVF

PCOS:

1st line: weight loss (adjunct: metformin)

2nd line: IVF

ALL:

• stop RF (stop smoking, exercise + weight loss, stop drinking, lose/gain weight)

Question 7

What is the definition of infertility and subfertility?

Answer 7

Infertility: unprotected vaginal intercourse with no conception for 12 months (refers to the couple).

Subfertility: using investigations, it is found that one of the couple is subfertile - decreased ability to conceive. Ie, lowered sperm count.