Infertility

Question 1

What is the definition of infertility?

How many couples suffer from this

Answer 1

Failure to achieve a pregnancy after 12 months or mor of regular unprotected sexual intercourse.

1/5 couples deal with this

Question 2

Primary vs secondary infertility

Answer 2

• Primary: not previously been pregnant and struggling now
• Secondary: Struggling now but have had one or more previous pregnancies

Question 3

What are the proportional causes of the infertility issues

Answer 3

Female Factors: 60%

• Disorders of the fallopian tubes and/or endometriosis
• Disorders of ovulation

Male Factors: 25%

• seminal abonormalities

Both male and female: 15%

Unexplained: 20-30%

Question 4

Female factors that make up for infertility account for ~60% of the aetiology. Of this disorders of the fallopian tube and ovulation are common. What specific types of issues can occur?

Answer 4

Ovulation Failure:

• PCOS (85%)
• hypothalamic amenorrhoea
• ovarian failure

Tubal Disease:

• PID
• Peritonitis
• Pelvic adhesions following bowel/pelvic surgery

Endometriosis:

Question 5

After one episode of PID ___% of women are female and after three episodes ____%

Answer 5

After one episode of PID 10% of women are female and after three episodes 50%

Question 6

anatomical and sperm reasons for an infertile male?

Answer 6

Anatomical:

• Congenital/acquired disease of hypothalamus or pituitary
• Cryptorchidism (undescended testes)
• Genetic abnormalities (Klinefelters)
• Surgery/trauma

Sperm:

• Abnormal spermatogenesis (2° to mumps, orchitis, chromosomal abnormalities, chemical/radiation exposure)
• oligospermia/azoospermia
• abnormal morphology or motility

Question 7

What is Fecundity? How is it measured

Answer 7

Capacity to concieve. Measured in a monthly probability of conception.

Question 8

Average monthly chance of conceiving in normal fertile couples is ____

Average duration for fertile couple to conceive is ___

Answer 8

Average monthly chance of conceiving in normal fertile couples is 20%

Average duration for fertile couple to conceive is 3 months

Question 9

What on examination of a women could indicate potential infertility?

Answer 9

General:

• Increased BMI
• Fat distribution central adiposity an indication of insulin resistance
• Short stature, webbed neck Turner’s
• Incomplete secondary sexual characteristics; hypogonadism
• Hirutism . PCOS

Abdominal Exam:

• scars, masses, tenderness

PV Exam:

• Tenderness in adexae . PID
• Palpable tender nodules . Endometriosis
• Vaginal/cervical abnormalities . Mullerian Abnormality

Question 10

What on examination of a man could indicate infertility?

Answer 10

• General observations. Vital signs, BMI. Presence of secondary sexual characteristics (hair distribution, muscle mass, adiposity)
• Gynaecomastia
• Abdomen or inguinal: scars from previous surgery
• External genital examination
  
  • Scars, penis (position of meatus),
• Scrotum:
  
  • testicular size (Prader orchidometer), consistency, presence of masses, location
  • epididymis: induration, engorgement, cyst
  • spermatic cord: presence of varicocele

Question 11

What investigations do you want to do on a female with suspected infertility?

Answer 11

• Full antenatal blood screen
  
  • Rubella, syphilis, HIV
  • Assess immunity to varicella if not positive history
  • Hepatitis B antigen (HBsAg), hepatitis C antibodies, HIV status
• STI swab for chlamydia and gonorrhoea
• HbA1c
• Cervical smear
• AMH level
• Day 2-4 of cycle: FSH level and oestrodiol levels
• Hormones
  
  • Progesterone (mid luteal rise > 30mmol/L in 3 cycles, 6-8 days before period – Ovulation >20nmol/l) If variable more then one measurement may be needed
  • Testosterone
  • LH (elevated days 2-5)
  • FSH • LH:FSH ratio (elevated in PCOS)
  • Thyroid (hypothyroidism)
  • Prolactin (produced by pituitary, increased levels interferes with ovarian function)
• USS • View follicle development or change to secretory endometrium.
• Laparoscopy/hysterosalpingogram • Assess tubal patency

Question 12

What does the AMH level measure?

Answer 12

Ovarian reserve

Question 13

What investigations could you do on a male with suspected infertiility?

Answer 13

• Semen Analysis: if abnormal repeat 4-6 weeks later
• Severe oligospermia/azoospermia
• Hep B antigen (HBsAg), hepatitis C antibodies, HIV status
• Scrotal ultrasonography

Question 14

How/when should you collect a semen sample?

Answer 14

Best collected via masturbation following 3 days of abstinenece and taken to labtests within 1hour of collection

Question 15

What are the indications for Scrotal USS

Answer 15

Indicated in patients with infertility + risk factors for testicular cancer

Also do a transrectal USS if obstructive azoospermia is suspected.