Infertility

Question 1

Lifestyle factors that affect fertility

Answer 1

• Age
• BMI
• Smoking
• Alcohol
• Recreational drug use
• Stress

Question 2

What is the WHO clinical definition of infertility? (in an individual)

Answer 2

Inability to conceive over a 12 month period despite exposure to regular, unprotected sexual intercourse

Question 3

What is the WHO epidemiological definition of infertility? (in a group)

Answer 3

Lack of conception after 2 years in women of reproductive age (15-49 years) who are at a risk of becoming pregnant (sexually active, not using contraception)

Question 4

When should a patient be referred to an infertility clinic?

Answer 4

• If <35 and no conception after 1 year of regular unprotected intercourse

Early referral if:

• >35 y/o and have been trying for 6 months
• There is a known cause for infertility

Question 5

Primary infertility

Answer 5

The male and female partner have never conceived before

Question 6

Main factors affecting a female’s fertility (5)

Answer 6

• Ovulatory dysfunction - not releasing an egg regularly i.e in PCOS
• Low ovarian (egg) reserve
• Tubal factor
• Uterine factor
• Endometriosis

Question 7

Main factors causing male infertility

Answer 7

• Problems in producing hormones for sperm production i.e hormone control
• Erection and ejaculation problems due to things like prostate surgery, nerve damage, timing of intercourse, medication
• Sperm production problems - genetic causes, failure of testes to descend, infection or torsion etc
• Blockage of sperm transport - infection, absence of vas deferens or vasectomy

Question 8

When beginning to investigate infertility what important factors/things do you want to find out?

Answer 8

Want to find out whether there are:

• Eggs available? - are they ovulating regularly
• Sperm available? is there enough and are they motile
• Can the sperm and egg meet? - ejaculation etc and is the fallopian tube in tact/patent?
• Any other factors - is the uterine cavity normal?

All these are necessary to have a spontaneous pregnancy

Question 9

How can you work out if a woman has a good ovarian reserve i.e eggs available?

Answer 9

• Age - steep decline after 35 years
• Ovarian reserve test - blood tests and scan
  
  • Blood test - FSH during day 1-5 of cycle (<10 iu/L) and Anti-Mullerian hormone (AMH) (5.0-25.0pmol/L)
  • USS - Antral follicular count - transvaginal - performed in the early phase of your menstrual cycle, in which you can visually count the number of egg-containing follicles that are developing on both of your ovaries.

Question 10

How can you determine whether ovulation is happening if there are sufficient egg supplies?

Answer 10

Couples can find out themselves by:

• Natural methods:
  
  • Basal body temperature - higher temperatures recorded when progesterone is at peak
  • Cervical mucus discharge - maximum around the time of ovulation
• LH ovulation kits
  
  • Detects surge of LH hormone
• Ovulation calendar or apps

One formal diagnostic test:

• D21 serum progesterone - levels of progesterone in the blood is taken on day 21 of a cycle if the woman has regular cycles (expect the hormone levels to be at peak at this point)
  
  • Expected levels = > 20nmol/l show satisfactory ovulation

Question 11

What invetsigation is done to determine whether a male has a sufficient amount of sperm available?

Answer 11

Semen analysis

Question 12

How to check fallopian tube patency?

Answer 12

• If no pelvic infection or gynaecological problem in past- Hysterosalpingogram (HSG)
  
  • Uses X-ray imaging. The uterus is filled with an iodine contrast using a catheter inserted in the cervix. As the dye enters the fallopian tubes, it outlines their length and spills out their ends if they are open (see image).
  • Abnormalities inside the uterine cavity may also be detected if the fluid movement is disrupted by the abnormality.
• If they have had a pelvic infection or gynae problem in the past then do Laparoscopic dye test
  
  • ​This is a surgical procedure under GA

Question 13

What are some other routine tests that need to be done for an infertile couple?

Answer 13

• Serum prolactin
• Thyroid function test
• Chlamydia screening
• Pelvic USS for uterine problems
• Also check- Rubella immunity
• Cervical smear uptodate and normal

Question 14

If a woman is found to have an ovulation disorder i.e irregular cycles, lack of ovulation…

1. How can this be managed?
2. What is the most common reason for this?

Answer 14

• Lifestyle factors
  
  • Optimise body weight
  • Healthy lifestyle i.e diet, smoking, alcohol etc
  • Exercise
• Medication
  
  • Clomiphene citrate - (ovulation induction - makes their cycle more regular)
  • Gonadotrophins - hormone replacement
• Surgical
  
  • Laparoscopic ovarian drilling

2. PCOS

Question 15

If a male is found to have a sperm problem i.e low sperm count or no sperm (azoospermia) how is it managed/treated?

Answer 15

Treatment depends on the cause of low sperm

If it is due to insufficient hormones driving sperm production:

• Gonadotropins - hormone replacement in order to drive sperm production

If the problem is in the testicle:

• Surgical sperm retrieval

If still no luck then options are:

• Donor sperm - intrauterine insemination
• ICSI - intracytoplasmic sperm injection - if manage to get some sperm from the father.

Question 16

What is the management for a female with tubal problems? (2)

Answer 16

• Surgical approach - limited to mild/minor tubal disease
• IVF - gives higher chance of conception

Question 17

What is the treatment for unresolved fertility?

Answer 17

IVF

Question 18

Describe the start of the IVF process for a female

Answer 18

• If a woman still has her cycle with her own eggs then she is given gonadotropin injections to stimulate the ovaries and produce multiple eggs in one cycle
• However, if the woman has reduced ovarian reserve, poor quality of eggs, her ovaries have failed prematurely or there is a genetic risk then she can receive donor eggs

Question 19

How is sperm sourced for IVF?

Answer 19

• If the male has sufficient sperm supply then they get a fresh sample on the day of egg retrieval or use a frozen sample from surgical retrieval or fertility preservation (i.e prior to cancer treatment)
• If the partner has no sperm or sperm is required for a single woman, same sex couple or there is risk of infection (HIV) or genetic cause then can use donor sperm

Question 20

Key steps in the IVF process

Answer 20

• First stimulate the ovaries to produce multiple eggs in a cycle - hormone injections given for a couple weeks
• Monitor the follicles in the ovaries with USS in 2nd week - check they’re growing
• Trigger ovulation with final injection of HCG (Human Chorionic Gonadotropin)
• 36 hours later do egg retrieval - simple procedure using transvaginal USS + insertion of needle into the follicles - get sperm sample on same day from partner
• Eggs are fertilised in dishes either by insemination (mixed into dish with egg) or Intracytoplasmic Sperm Injection (sperm injected into the egg)
• Incubation/embryo development (3-5 days, no more than 6)
• Embryo transfer - suitable embryo is selected for this - inserted into mother’s uterus. Freeze any other suitable ones
• Progesterone support - vaginal pessaries - maintain endometrium for pregnancy
• Pregnancy test after 2 weeks - if positive - scan at 7 weeks

Question 21

Risks of IVF treatment

Answer 21

• Ovarian hyperstimulation syndrome (OHSS) - as a result of hormone administration there could be an overresponse of the ovaries and production of multiple follicles - gives rise to symptoms
• Multiple pregnancy - transferring more than one embryo
• Medication side effects - minor usually
• Procedure related - bleeding or infection (Rare)