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What physiological events are required for conception?



What is the NICE definition for an infertile woman?

A woman of reproductive age who has not conceived after one year of unprotected sexual intercourse


What causes subfertility?

-Male factor
-Tubal factor
-Subtle factors that are not detectable on routine investigation.


What is the difference between infertility and subfertility?

Infertility: inability to achieve a pregnancy
Sub-fertility: any form of reduced fertility with a prolonged time of unwanted non-conception


Define primary & secondary infertility

-Primary infertility:someone has never achieved a pregnancy before

-secondary infertility: someone has had a pregnancy before ( baby,miscarriage, T.O.P included). For example, it could be after an ectopic pregnancy where you have a Fallopian tube removed


What various risks of tubal disease exist?

-history of endometriosis


What is the effect of smoking on fertility?

-Reduces women's fertility
-Reduces semen quality


What factors may contribute to male infertility

-drugs (therapeutic& recreational)
-testicular maldescent
-infections( STI,mumps orchitis)


What is testicular maldescent?

-A condition in which one or both of the testicles don't move all the way down into the scrotum
-A lot of the time this doesn't get recognized till their 7-9 yrs and in that time they would've had significant damage to their spermatogenesis


What basic investigations are used to investigate infertility?

-semen fluid analysis
-pelvic anatomy and tubal patency
-ovarian reserve


How can we assess the pelvic anatomy and fallopian tubes patency?

-Laparoscopy& dye: Gold standard in tubal patency evaluation. You inject the dye through the cervix and visualize the dye coming from the fallopian tubes
-Hysterosalpingogram (HSG):a radiologic procedure to investigate the shape of the uterine cavity and the shape& potency of the fallopian tubes
-Hystero contrast sonogram (Hycosy): ultrasound procedure, a dynamic test to investigate the fallopian tubes.


What is the significance of ovarian reserve

- The number & quality of oocytes decline with a woman's age,as does her overall fertility
-Measures to assess ovarian reserve are used to predict the likelihood of a successful response to ovarian stimulation with assisted reproduction treatment, although it seems to have a poor correlation with pregnancy outcomes
-Testing for ovarian reserve is mainly a measure of quantity but also reflects the quality of the oocytes
-A woman's age at the time of treatment= the best predictor for oocyte quality


What can we use to predict the ovarian reserve?

-Early follicular FSH (reflects what the pituitary is doing in response to the number of eggs). An elevated value is highly sensitive for identifying women with a depleted ovarian follicular pool
-AFC: best checked in the early follicular phase; inter-observer variability; correlates well. Good accuracy for predicting poor response in regularly cycling women but not a good test for pregnancy prediction
-AMH: produced by the granulosa cells, from the pre-atral and antral follicles; can be measured anytime in the cycle and intercycle varibility is reported to be low; accurately measured in women receiving hormonal contraception
-Response achieved during an ART( Assistive Reproduction Technology-e.g IVF) may be the best predictor for ovarian reserve


What other investigations may be useful when investigating infertility?

-Day 2-4 hormone profile (FSH,LH,PROLACTIN,TSH,TESTOSTERONE)
-cervical smear
-chlamydia swabs
-viral serology (Hep B. Hep C, HIV)


What treatment options are available for infertility?

-Assisted conception
-ICSI (Intracytoplasmic Sperm Injection)


What are the different causes of anovulation?

-hypothalamic dysfunction
-pituitary dysfunction
-thyroid dysfunction
-Ovarian failure


How do we classify anovulation according to WHO

-Group 1: hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism)
-Group 2: hypothalamic-pituitary-ovarian dysfunction (predominanalty PCOS)
Group 3: Ovarian failure


What treatment can be used for ovulation induction?

-Clomiphene citrate


What is Azoospermia?

-Obstructive azoospermia(normal spermatogenesis), normal sized testes and FSH level. Could be: post infection; post vasectomy; congenital absence of vas deferens
-Non- obstructive azoospermia(impaired spermatogenesis), small testes raised FSH: testicular failure; 50% have evidence of spermatogenesis on testicular biopsy


How do we retrieve sperm for ICSI?

Intracytoplasmic Sperm Injection
-local anasesthetic
-outpatient procedure
-Samples may be stored for future cycles
-Percutaneous sperm aspiration(PESA)
-Testicular sperm extraction (TESE)