Subfertility

Question 1

Subfertility Hormonal Ix

Answer 1

Blood hormone profile:
- Day 2/3 FSH LH
- AMH for ovarian reserve
- Midluteal progesterone to confirm ovulation
Consider TFT, prolactin, testosterone if irregular periods

Question 2

If considering assisted repro what needs screening

Answer 2

HIV, HBV, HCV screen

Question 3

Subfertility other Ix

Answer 3

• STI screen
• TVUSS (anatomy, follicle count)
• Ovarian reserve (response to ART)
• Tubal assessment
• Semen analysis

Question 4

How to measure ovarian reserve?

Answer 4

• Antral follicle count (AFC) seen on TVUSS is a good indicator of ovarian reserve
  <4 = poor response
  >16 = good response
• AMH: prod. by granulosa cells, does not change in response to gondatrophins

AMH best biomarker, clinics use both

Question 5

What is ovarian reserve?

Answer 5

number of oocytes remaining directly in ovaries, it is proportional to female reproductive potential

Question 6

Tubal assessment in subfertility

Answer 6

Hysterosalpingography using X-ray/USS or laparoscopy and dye
Patency does not equal function
only performed if risk of tubal damage e.g PID, endometriosis, ectopic

Question 7

Semen analysis in subfertility

Answer 7

2 tests 3mo apart

Question 8

Medical Mx Indications of Subfertility

Answer 8

Anovulation
Unexplained subfertility
Male factor inc. aspermia
Mild to minimal endometriosis
Single women
Same sex couple
Poor egg quality
Previous chemo/surg w/affected ovaries

Question 9

Medical Mx of subfertility

Answer 9

• Anovulation: clomiphene/FSH
• IU insemination: unexplained, mild male, minimal/mild endomet.
• Donor Insemination: aspermia, single women, same sex couple
• IVF:
  tubal pathology, previous other mx failure
• Donor egg w/IVF:
  egg quality poor, prev. surg/chemo

Question 10

Indications for Surgical Mx of Subfertility

Answer 10

1. Laparoscopy:
   - adhesions, endometriosis, cysts
2. Myomectomy/fibroid embolistation
   - Fibroid
3. Tubal surgery:
   - blocked tubes amenable to repair
4. Laparoscopic ovarian drilling:
   - PCOS non-responsive to medical mx

Question 11

PACES counselling Subfertiltiy

Answer 11

RF: age, smoking and alcohol, irregular periods, STI
Still a chance naturally (15% fail after 1yr)
Ix: hormones, USS, ?HSG
Encourage regular unprotected sex