Tutorial 13: Infertility

Question 1

What is the definition of Infertility?

Answer 1

Failure to conceive after 12 months of unprotected intercourse

Question 2

What are the two types of infertility?

Answer 2

Primary Infertility: Couple who has never been able to conceive.

Secondary Infertility: Couple who find it difficult to conceive having already conceived in the past (could have had a term pregnancy or may have experienced miscarriage).

Question 3

What is Fecundity?

Answer 3

Fecundity is the capacity to conceive and is measured as the monthly probability of conception.

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

Average duration for fertile couple to conceive is 3 months.

Age dependent.

Question 4

What lifestyle factors effect Fecundity?

Answer 4

– Smoking (damages eggs, fallopian tubes, sperm, affects hormones in men/women, miscarriage risk, ectopic pregnancy)

– Moderate/heavy EtOH (age dependent)

– Weight (over/under – affects ovulation)

– Exercise (none or excessive)

– Medication - steroids

Question 5

What are the most common causes of infertility, in descending order?

Answer 5

Infertility- 1/6 couples failing to conceive

• 33% male factors
• 20% anovulation
• 15% tubal factors
• 10% endometriosis
• 5-10% cervical factors
• 15% unexplained (includes stress & environmental factors)

Question 6

What are causes of infertility in a woman?

Answer 6

Anovulation

• premature ovarian failure
• PCOS
• hypothalamic/pituitary insufficiency
• hyperprolactinaemia
• metabolic disease (thyroid, renal, liver, underweight or obese)

Tubal factors

• PID (1 episode 10%, 3 episodes 50%) o previous ectopic pregnancy
• adhesions, endometriosis
• peritoneal infections

Cervical factors

• congenital, infection, post-surgery

Question 7

What Hx and Ex would you do for Infertility?

Answer 7

History

• General - Age, occupation/environment, folate in diet, smoking, drugs and EtOH
• Specific symptoms – acne, hirsutism, dysmenorrhoea etc
• Intercourse – timing (in relation to ovulation) and frequency (>2 x per month)
• Menstrual history
• Past obstetric history (pregnancies, miscarriages)
• Contraception
• Gynaecological history

Examination

• General inspection
• Height, weight, BMI
• Vitals: HR, BP, RR, Temp (incr 0.3oC post-ovulation), Sa02
• Endocrine/systemic disease – including PCOS (evidence of hirsutism, acne, and alopecia)
• Abdomen: shape, scars, tenderness
• Pelvis (with chaperone/ supervisor):
  
  • External genitalia
  • Speculum – Cervix
  • +/- smear, pipelle, HVS/endocx swab
  • Bimanual – uterine size, tenderness, adnexal masses

Question 8

What Investigations would you do for a female with infertility?

Answer 8

• Infective Screen: hepatitis, rubella, chlamydia, and gonorrhoea
• Hormones:
  
  • Progesterone (mid luteal rise > 30mmol/L in 3 cycles)
  • 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 9

What are causes of infertility in a male?

Answer 9

Sperm

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

Anatomical

• congenital
• obstruction of vas deferens
• varicocele (varicosities in spermatic cord veins)
• 2° to infection (mumps, STIs, prostatitis)
• surgery or trauma

Endocrine

• hyperprolactinaemia
• hypothalamic or pituitary failure (tumour, radiation or surgery)
• exogenous androgens
• adrenal hyperplasia

Sexual dysfunction

Question 10

What Hx and Ex would you do for a male with infertility?

Answer 10

History

• Intercourse – frequency
• Erection/ejaculation problems
• Pubertal development
• Previous fatherhood
• Previous STI
• Previous surgery – especially GU tract
• Social- smoking, EtOH, environmental toxins, illicit drug use

Examination

• Evidence of gynaecomastia, eunuchoidal features (testes are present but fail to function normally; may be of gonadal or pituitary origin)
• Secondary sexual characteristics
• Genital examination
  
  • Particularly testicular volume/size
  • Vas deferens palpation

Question 11

What Investigations would you do for a male with infertility?

Answer 11

Semen analysis

• volume > 2 mL
• density > 20 mil/mL
• motility > 50%
• normal morphology > 70%

Blood Tests

• FSH (1o testicular failure, pituitary dysfxn)
• Testosterone + LH (androgen deficiency)
• Karyotyping (exclude chromosomal abnormality)

Others- swabs for chlamydia and Gonorrhoea, post-coital test (>20 motile sperm/HPF)

Question 12

What general management would you do for infertility?

Answer 12

Depends on aetiology

General Measures

• Coital timing
  
  • Every 2 days in peri-ovulatory period, days 12-16
• Emotional support
• Lifestyle factors
  
  • Smoking cessation, weight loss (BMI 19-25), healthy diet, caffeine reduction

Question 13

What specific treatment measures would you do for infertility?

Answer 13

PCOS

• weight loss
• clomiphene citrate (anti-oestrogen, increases FSH in early follicular phase)
• Metformin (improves insulin sensitivity)
• Recombinant FSH (direct ovarian stimulation, risk of multiple pregnancy)

Tubal disease: Hysterosalpingogram, manual removal or balloon tuboplasty, IVF if severe

Endometriosis – IVF

Male factors

• Intrauterine insemination (IUS)
• Intracytoplasmic injection ( ICSI)

Idiopathic: Empiric clomiphene, IVF, IUI

Question 14

What is the Diagnostic criteria for PCOS?

Answer 14

Disorder of hypothalamo-pituitary-ovarian axis characterised by raised LH and testosterone in 50% of cases.

Diagnostic Criteria (>2 of following)

1. Evidence of oligo or anovulation
2. Clinical and/or biochemical evidence of androgen excess
3. Ultrasound evidence of polycystic ovaries
   
   1. Enalrged ovaries
   2. Ring of follicles in the periphery
   3. Stromal hypertrophy

Question 15

What are the signs and symptoms of PCOS?

Answer 15

Common:

• Menstruation irregularities (75%)
• Overweight (30-80%)
• Hirsutism (60% of women with PCOS)
• Acne (15-25%)
• Hypertension
• (Affecting women of reproductive age)

Uncommon:

• Scalp Hair Loss
• Oily skin or excessive sweating

Question 16

What are some of the long term complications of PCOS?

Answer 16

1. Infertility
2. Pregnancy complications: GDM, pregnancy induced HTN, pre-eclampsia, preterm delivery etc.
3. Cardiovascular Disease: Dyslipidaemia, metabolic syndrome
4. Type 2 Diabetes
5. Non alcoholic fatty liver disease
6. Psychological complication
7. Obstructive Sleep Apnoea