infertility

Question 1

definition of infertility

Answer 1

failure to achieve a clinical pregnancy after 12 months of more of regular unprotected sexual intercourse (in absence of known reason) in a couple who have never had a child (WHO definition)

Question 2

what factors increase chances of conception

Answer 2

• Woman aged under 30 years
• Previous pregnancy
• Less than three years trying to conceive
• Intercourse occurring around ovulation
• Woman’s body mass index (BMI) 18.5 – 30m/kg2
• Both partners non-smokers
• Caffeine intake less than two cups of coffee daily
• No use of recreational drugs

Question 3

what are some common causes of secondary infertility

Answer 3

• tubal disease
• fibroids
• endometriosis/adenomyosis
• weight related
• age related

Question 4

gynaelogical conditions that cause anovulatory infertility

Answer 4

• anorexia, bulimia, excessive exercise
• hyperprolactinaemia, tumours, Sheehan syndrome
• PCOS, premature ovarian failure

Question 5

other conditions that cause anovulatory infertility

Answer 5

• Systematic disorder: e.g. chronic renal failure.
• Endocrine disorder: e.g. testosterone secreting tumours, congenital adrenal hyperplasia, thyroid
• Drugs: e.g. depo-provera, explanon, OCP

Question 6

clinical features of PCOS

Answer 6

obesity, hirsutism or acne, menstrual cycle abnormalities and infertility

Question 7

endocrine features of PCOS

Answer 7

high free androgens, high LH, impaired glucose tolerance

Question 8

diagnosis of PCOS

Answer 8

score 2 out of three:

• chronic anovulation
• polycystic ovaries
• hyperandrogenism (clinical or biochemical)

Question 9

clinical features of premature ovarian failure

Answer 9

hot flushes, night sweats, atrophic vaginitis, amenorrhoea, infertility

Question 10

endocrine features of premature ovarian failure

Answer 10

high FSH, high LH, low oestradiol

Question 11

infective causes of tubal disease

Answer 11

• Pelvic inflammatory disease (chlamydia, gonorrhoea, other: anaerobes, syphilis, TB)
• transperitoneal spread: appendicitis, intra-abdominal abscess
• following procedure: IUCD insertion, hysteroscopy, HSG

Question 12

non-infective causes of tubal disease

Answer 12

• endometriosis
• surgical (sterilisation, ectopic pregnancies)
• fibroids
• polyps
• congenital
• salpingitis isthmica nodosa

Question 13

clinical features of hydrosalpinx

Answer 13

• abdominal/pelvic pain febrile
• vaginal discharge dyspareunia
• cervical excitation menorrhagia
• dysmenorrhoea
• infertility
• ectopic pregnancy

Question 14

what is endometriosis

Answer 14

presence of endometrial glands outside uterine cavity

Question 15

causes of endometriosis

Answer 15

Retrograde menstruation is most likely cause, altered immune function, abnormal cellular adhesion molecules, genetic

Question 16

clinical features of endometriosis

Answer 16

dysmenorrhoea (classically before menstruation), dysparenuia, menorrhagia, painful defaecation, chronic pelvic pain, uterus may be fixed and retroverted, scan may show characteristic ‘chocolate’ cysts on ovary, infertility, asymptomatic

Question 17

drugs that cause male infertility

Answer 17

• alcohol
• SSRI anti-depressants
• tobacco
• cocaine
• marijuana
• testosterone supplements

Question 18

clinical features of non-obstructive male infertility

Answer 18

low testicular volume
reduced secondary sexual characteristics
vas deferens present

Question 19

endocrine features of non-obstructive male infertility

Answer 19

High LH, FSH and low testosterone

Question 20

clinical features of obstructive male infertility

Answer 20

normal testicular volume
normal secondary sexual characteristics
vas deferens may be absent

Question 21

endocrine features of obstructive male infertility

Answer 21

Normal LH, FSH and testosterone

Question 22

investigation of infertility

Answer 22

infertility history, gynaecology, andrology, sexual history, social history, PMH, PSH, POH

Question 23

examination of female infertility

Answer 23

• BMI
• General examination, assessing body hair distribution, galactorrhoea
• Pelvic examination, assessing for uterine and ovarian abnormalities/tenderness/mobility

Question 24

examination of male infertility

Answer 24

• BMI
• General examination
• Genital examination, assessing size/position testes, penile abnormalities, presence vas deferens, presence varicoceles

Question 25

investigations for female infertility

Answer 25

- endocervical swab for chlamydia - cervical smear if due - blood for rubella immunity - midluteal progesterone level (day 21 of 28 day cycle or 7 days prior to expected period in prolonged cycles), -progesterone > 30nmol/l suggestive ovulation - Test of tubal patency: hysterosalpingiogram (HSG) /hycosy or laparoscopy

Question 26

investigations for male infertility

Answer 26

- History (PMH, occupation, drugs, social, andrology) - Examination (general and genitalia) - Semen analysis: twice over 6 weeks apart

Question 27

what are some vitamin supplements for infertility

Answer 27

- folic acid | - vitamin D

Question 28

management of hypothalamic anovulation

Answer 28

- stabilise weight - pulsatile GnRH - gonadotrophin daily injections - USS of ovarian response

Question 29

how is ovulation inducted in PCOS

Answer 29

- clomifene citrate - gonadotrophin daily injections - laparoscopic ovarian diathermy

Question 30

what can reproductive surgery be used for

Answer 30

- pelvic adhesions - grade 2 endometriosis - chocolate cysts in ovary - tubal block

Question 31

treatment for women with proximal tubal obstruction

Answer 31

- selective salpingography plus tubal catheterisation | - hysteroscopic tubal cannulation

Question 32

how should submucosal fibroids be treated

Answer 32

hysteroscopically to improve conception rates

Question 33

treatment of male infertility

Answer 33

Surgery to obstructed vas deferens (50% success following vasectomy) Intrauterine insemination in mild disease Intracytoplasmic sperm injection (ICSI) Surgical sperm aspiration from epididymis or testicle combined with ICSI Donor sperm insemination.