Subfertility

Question 1

Define subfertility

Answer 1

Failure to conceive after one year of regular unprotected intercourse

Question 2

What is the incidence of subfertility?

Answer 2

15%

Question 3

What aspects should you ask about in the history of the male partner?

Answer 3

HxPC:

1. Length of time trying
2. Any symptoms of erectile dysfunction
3. Ix or Tx so far
4. Any child from previous relationship

PMed/Surg:

1. Undescended testes
2. Mumps orchitis
3. Cancer

Sexual Hx:
1. Previous STIs

Social Hx:

1. Occupation
2. Alcohol
3. Drug use

Question 4

What aspects should you ask about in the history of the female partner?

Answer 4

HxPC:

1. How long trying
2. What Ix and Tx so far
3. Menarche, periods - duration, cycle, menstrual diary
4. Are they timing intercourse around ovulation

PMed Hx:

1. Chronic conditions
2. Thyroid
3. DM

P Gynae Hx:

1. STIs
2. PID
3. PCOS
4. Gynae conditions

P Obs Hx:
1. Past pregnancies if any

Medications:

1. Folic acid
2. Other meds

Social Hx:

1. Smoking
2. Alcohol
3. Drug use
4. Occupation

Question 5

What would you look for on examination in the male partner?

Answer 5

1. General medical examination
2. Height - Klinefelter’s syndrome (taller)
3. Inguinal scars
4. Size/site of testes
5. Varicocoele/epididymal cyst

Question 6

What would you look for on examination in the female partner?

Answer 6

1. General:
   - exophthalmos
   - anaemia
   - goitre
   - hirsutism
   - BMI
2. Pelvic examination:
   - Masses
   - Cx smear

Question 7

List the causes of subfertility

Answer 7

1. Anovulation
2. Male factor
3. No fertilisation
4. Unexplained

Question 8

List the causes of anovulation

Answer 8

1. PCOS
2. Hypogonadism
3. Hyperprolactinaemia
4. Thyroid dysfunction
5. Ovarian failure

*30% of subfertility

Question 9

List the causes of male factor subfertility

Answer 9

1. Idiopathic
2. Varicocoele
3. Antibodies
4. Drugs/chemical exposure

*25% of subfertility

Question 10

List the causes of no fertilisation

Answer 10

1. Tubal damage:
   - Infection
   - Surgery
   - Endometriosis
2. Cervical <5%
3. Sexual factor 5%

Question 11

What percentage of subfertility is unexplained?

Answer 11

30%

Question 12

What investigations would you do for subfertility in the female?

Answer 12

BLOODS:

1. D21 progesterone >30nmol/L (to confirm ovulation) (taken 7days before the subsequent menstruation so may not be D21 depending on length of cycle, mid luteal phase)
2. D3 FSH/LH
3. Testosterone, prolactin, TFTs
4. Rubella status
5. Anti-mullerian hormone (test of ovarian reserve, not 1st line)

USS:

• PCO
• Can monitor follicular growth (generally not done)

LH hormone based urine predictor kits:
- OTC (indicate if LH surge has taken place)

TUBAL PATENCY:

• Laparoscopy and dye
• Hysterosalpingogram (less invasive, do this first)

Question 13

What investigations would you do for subfertility in the male?

Answer 13

Semen analysis

Question 14

List the WHO criteria for semen analysis

Answer 14

1. Volume >1.5mls
2. Sperm count >15 million/ml
3. Progressive motility >32%
4. Morphology >4% normal

Question 15

How do we do semen analysis?

Answer 15

• Specimen needs to be produced by masturbation and not into a condom
• Done after 2-5 days of abstinence
• Specimen needs to be kept at body temperature, and bought to the lab within 1hr from production

Question 16

What do we do if semen analysis is abnormal?

Answer 16

• Can repeat 3mths after initial analysis (allows time for cycle of spermatozoa formation to complete)
• If gross spermatozoal deficiency test should be repeat ASAP

Question 17

List the causes of abnormal semen analysis?

Answer 17

1. Unknown
2. Smoking/alcohol/drugs
3. Varicocele
4. Antisperm antibodies
5. Klinefelter’s syndrome
6. CF mutation carrier

Question 18

What are the general treatment options for subfertility?

Answer 18

1. Weight loss
2. Lifestyle advice
3. Folic acid

Question 19

How is tubal factor subfertility treated?

Answer 19

1. Laparoscopic surgery if mild/endometriosis

2. IVF if fails or severe

Question 20

What is the treatment for anovulation?

Answer 20

1. Clomiphene
   - Selective oestrogen receptor modulator (SERM). Causes release of GnRH by the hypothalamus
   - SEs = Twins 10%, blurred vision, OHSS
2. Metformin
3. Gonadotrophins

Question 21

What is the surgical treatment of PCOS?

Answer 21

Ovarian diathermy

Question 22

How can we treat male factor infertility?

Answer 22

1. IUI
2. IVF with or without ICSI
3. DI

Question 23

What to we use in cases of unexplained subfertility?

Answer 23

1. IUI

2. IVF

Question 24

What are the criteria for diagnosis of PCOS?

Answer 24

At least 2 of following 3 criteria must be met:

1. Polycystic ovaries on ultrasound
2. Irregular periods (>35days apart)
3. Hirsutism - clinical (acne or excess body hair) and/or biochemical (raised serum testosterone)

Question 25

List the clinical features of PCOS

Answer 25

1. PCO 2. Obese 3. Acne 4. Hirsutism 5. Oligomenorrhea or amenorrhea 6. Miscarriage more common

Question 26

List the complications of PCOS

Answer 26

1. T2DM 2. GDM 3. Endometrial cancer

Question 27

How can we treat the other symptoms of PCOS besides infertility?

Answer 27

1. Advice regarding diet and exercise 2. COCP will normalise menstruation if fertility not required 3. Anti-androgens (cyproterone acetate or spironolactone) effective for hirsutism but conception must be avoided 4. Eflornithine - topical anti-androgen for facial hirsutism

Question 28

What are the key points about Clomifene?

Answer 28

1. Traditional 1st line ovulation drug in PCOS 2. Limited to 6mths use (as anti-oestrogen) 3. Only given at start of cycle - initiates follicular maturation 4. Monitored by TVUS 5. If no follicles develop dose increased in subsequent cycles 6. If 3 or more follicles develop, cycle cancellation initiated to decrease risk of multiple pregnancy

Question 29

What are the key points about metformin?

Answer 29

1. Insulin sensitising drug used to restore ovulation 2. Does not promote ovulation so no increase in multiple pregnancy 3. Taken every day throughout cycle in multiple doses 4. GI SEs common 5. Treats hirsutism

Question 30

What are the key points about laparoscopic ovarian diathermy?

Answer 30

1. Second line tx 2. As effective as gonadotrophins 3. Lower multiple pregnancy rate 4. Each ovary monopolar diathermised at a few points for a few seconds 5. Tubal patency tested during same operation

Question 31

What are the key points about gonadotrophin induction of ovulation?

Answer 31

1. Used when first line treatments have failed 2. Also given in hypothalamic hypogonadism when weight is normal 3. Usually maturation of more than one follicle 4. In PCOS low dose step-up regimen 5. Follicular developments monitored via US 6. Follicle of adequate size for ovulation - artificial stimulation of ovulation by injection of hCG or recombinant LH

Question 32

List the side effects of ovulation induction

Answer 32

1. Multiple pregnancy 2. Ovarian hyperstimulation syndrome (OHSS) 3. Ovarian and breast carcinoma

Question 33

Define ovarian hyperstimulation syndrome (OHSS)

Answer 33

Overstimulation of the follicles in the ovaries and they get very large and painful. More common during IVF than standard ovulation induction

Question 34

List the risk factors for OHSS

Answer 34

1. Gonadotrophin stimulation 2. Age <35yrs 3. Previous OHSS 4. Ovaries of polycystic morphology on US

Question 35

How can we prevent OHSS?

Answer 35

1. Use lowest effective dose of gonadotrophin doses 2. US monitoring of follicular growth - if excessive withdrawal of gonadotrophins for a few days or cancellation of IVF cycle (withholding hCG injection)

Question 36

What happens in severe cases of OHSS?

Answer 36

1. Hypovolaemia 2. Electrolyte disturbances 3. Ascites 4. Thromboembolism 5. Pulmonary embolism * CAN BE FATAL