TEALE FENNING

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 918

A couple comes to your fertility clinic and have been trying for 3 years.

A . What points in the history will alert you to the cause? 8 marks

B. What investigations will you offer them as a first line? 3 marks

C. What preconception advice will you give the couple? 9 marks

This is one of those questions where it's easy to forget points. this will probably have a high pass mark.

Ok Farah and all others -- give this a try.

r
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SpR O&G Wessex Region

shachi · Joined: 10 Jun 2008 Posts: 16

Hi all,
This is Shachi.

Have manged to cook up an essay for Raj's question. Very Happy

What points in the history will alert you to the cause?

It is important to know the frequency of intercourse, any coital problems like dyspareunia, ejaculation & erection problems, length of relationship, duration of trying for conception without using contraception. The type of contraception, if used is important as depot provera can cause delay in return to fertility.
A detailed gynaecological, obstetrics, medical, surgical social and family history should be taken from both partners.
Age of female patient is important as female fertility declines with age.
A detailed gynaecological history, including age of menarche, length of cycle, duration and amount of bleeding during periods and dysmenorrhea is important. A history of dysmenorrhea, dyspareunia & menorrhagia might point to a diagnosis of endometriosis. A history of previous sexually transmitted diseases, chlamydia, pelvic inflammatory disease, chronic pelvic pain, might point to a diagnosis of tubal fertility secondary to adhesions and infections. Tubal damage may be indicated in patient with history of previous ectopic or previous tubal surgery.
A history of oligomennorhea, hirsuitism and acne may indicate a diagnosis of polycystic ovarian disease.
Delayed menarche with oligo or amenorrhea may indicate a genetic or congenital cause.
A history of menorrhagia, cold intolerance and lethargy may indicate hypothyroidism.
Galactorrhea, irregular periods, visual disturbance may be seen in prolacinomas.
Hypertension in an obese patient with irregular periods may instigate investigations for endocrine causes like cushing’s disease.
History of oligo-amenorrhea, weight loss and decreased appetite with psychological problems could be due to anorexia nervosa.
A history of radiotherapy or chemotherapy may prompt investigations for premature ovarian failure.
Smoking and alcohol itself can affect fertility in many men and women.
A past history of mumps, orchitis or testicular trauma in male partner may indicate testicular damage.
Previous inguinal hernia repair, orchidopexy
Family history may point to a diagnosis of cystic fibrosis.
Previous radiotherapy or chemotherapy for cancer could affect spermatogenesis.
Medications like sulphasalazine can affect spermatogenesis.

What investigations will you offer to them as first line? (3)

Investigations for female partner include a folicular phase Leutinising hormone and Follicle stimulating hormone to check for ovarian reserve (raised FSH), to rule out polycystic ovarian syndrome (reverse LH/FSH ratio) and to exclude hypogonadotrophic hypogonadism (decrease LH and FSH). Serum estradiol and day 21 progesterone should be done if cycles regular, the latter to check for ovulation.
Tests for tubal patency include Hysterosalpingogram, Hycosy, laparoscopy and dye test. The choice of test depends on history and facilities available and should be precede by chlamydia screen.
Serum prolactin, thyroid function tests, serum testosterone, SHBG can be done if indicated in history. All females with primary fertility should have rubella screen.
All male partners should be offered semen analysis. At least 2 samples should be done 3 months apart.

What preconception advice will you give to the couple? (9)

Preconception folate till 12 weeks of gestation to reduce the risk of neural tube defects in baby.
Regular intercourse 2-3 times a week optimises chances of pregnancy. No benefit from timing with ovulation, it only adds to stress.
Stop active and passive smoking and drinking and drugs.
There is an association between smoking and reduced semen quality. Smoking is likely to reduce fertility in females. Offer a referral to smoking cessation programmes.
If any medical problem, optimise treatment and use contraception till optimised. These patients should be referred to preconception counselling clinics so where they can also alter or stop drugs which adversely affect fertility or which are harmful to baby.
Male should wear loose fitting underwears and avoid working in high temperatures as high temperaures can reduce fertility.
Offer psychosexual counselling if indicated.
Women with body mass index more than 29 should be adviced that they may take longer to conceive and if not ovulating, then losing weight is likely to increase chance of conception.
Men with body mass index more than 29 is likely to reduce fertility.
Women who have a body mass index of less than 29, have improved chances of conception by increasing body weight.

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 918

Hi Shachi,

welcome to the forum. a very good attempt indeed.

stem 1 --- a few things that i was specifically looking for were, for example.

age --
decrease in quality of eggs. fecundity at 35-39 is half that at 19-26 yrs age. some recent data suggests that male fertility also decreases with age.
at 35+ cumulative pregnancy rate are only 60% in the 1st year as opposed 85% in younger population.

just saying fertility declines with age is not enough in the part 2.

you have repeated comments about radio - chemo separately for male/female partner -- try and club things like this together. there is limited space on the answer sheet and trying to economize will allow you to get more points in

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 918

Stem 2 --

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 918

stem 3 --- this is a good attempt

frequency of intercourse --- max chances of conception are if intercourse 6 days prior to 2 days after ovulation hence the 2-3/week is the right advice from day 8 onwards.

add checking rubella status - if non immune consider / offer pre - pregnancy and 1 month of contraception after immunisation.

r
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SpR O&G Wessex Region

Abik · Posted: Thu Jun 19, 2008 1:33 pm Post subject:

Hey Shachi,
Great answer - loads and loads of information, Mr Brook has clearly got you thinking!!!

Raj is right though - Nick talks about the two birds fluttering around your head all the time - the "why-why" birds. If you write a sentence that does not have a justification you may as well spend the time picking your nose for all the marks it will get you.

Spend more time thinking and less time writing.
Compress your sentences.
A history of.... is suggestive of..... etc. etc.

More practice - thats' all it takes!!!
Abi