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Infertility

Clinical Discipline(s)/Organ System(s)
Obstetrics & Gynaecology, Reproduction & Development, Genitourinary System, Ethics
Progress Test Topic(s)
Women's health
Description
A 28 year old NZ European woman has been trying to conceive for 2 years without success. Her partner is 34 years old and they have sexual intercourse regularly. He attends the clinic with her.
Applied Science for Medicine 
   - Anatomy and function of the male and female reproductive tracts
   - Physiology of the female and male hypothalamic-pituitary-gonadal axis and its effects on target organs including the normal menstrual cycle, ovulation and fertile period
   - Physiology of follicle maturation, ovulation and atresia
   - Physiology of spermatogenesis
   - Physiology of conception, factors, conditions and hormones required for successful conception
   - Mechanisms of sexual arousal, intercourse and orgasm/ejaculation
   - Pathophysiology of the hypothalamic-pituitary-ovarian axis: hyperprolactinaemia, stress, anorexia, thyroid dysfunction
   - Pathophysiology of polycystic ovary syndrome (PCOS) and premature ovarian failure (POF)
   - Pathophysiology of disorders of spermatogenesis
   - Pharmacology of clomiphene, gonadotrophins, metformin
Clinical and Communication Skills 
   - Elicit a comprehensive gynaecological history (including menstrual history, sexual history), medical, surgical and obstetric history
   - Examination, including general (to recognise anorexia, visual field defects, secondary sexual characteristics and syndromes), abdomen and pelvis
   - Take a history from the male partner and examine him, including testicular examination
   - Recognise risk factors for infertility (female factor, male factor and couple factor)
   - Define infertility and classify it as primary or secondary
   - Differential diagnosis of infertility (female, male and couple aetiologies, unexplained)
   - Presenting symptoms and signs of endometriosis, PCOS, hyperprolactinaemia and premature ovarian failure
   - Appropriate initial investigations: antenatal screen, Day 2-4 follicle-stimulating hormone (FSH), luteal phase progesterone, semen analysis
   - Interpret relevant investigations for both partners
   - Outline the management of an infertile couple
   - Appropriate referral to fertility specialist
   - Pre-pregnancy folate and iodine supplementation, screening and vaccinations
   - Knowledge of types of sexual dysfunction
Personal and Professional Skills 
   - Psychological and social impact of infertility
   - Being able to manage couples sensitively who are dealing with a highly emotional life event
   - Demonstrate skillful communication for talking to two people who may have different opinions
   - Communicate sensitively and empathically in potentially emotional situation
   - Explore (separately) whether both members of the couple want a child
   - Managing patient's expectations: unexplained infertility, maternal age, relationship strain
   - Discuss issues such as adoption, sperm and egg donation
   - Ethics associated with treatment
   - Counselling on lifestyle changes
   - Intimate examination and use of chaperone
   - Consider the reproductive needs of women in same sex couples
   - Role of sexual therapist and psychologist
   - Respect the principle of autonomy
   - Recognise people vulnerable to exploitation
   - Ensure culturally appropriate support (e.g. spiritual) for the couple
   - Awareness of own views on having children, possible self-identification with patient, and professional boundaries
Hauora Māori 
   - Recognise the differing risk pattern for Māori (higher rates of gonorrhoea, chlamydia, ectopic pregnancy and tobacco use during fertile years)
   - Māori attitudes to assisted reproduction
Population Health 
   - Epidemiology of infertility
   - The role of sexually transmitted infections in tubal factor infertility
   - Effect of women delaying childbearing on fertility
Conditions to be considered relating to this scenario
Common
polycystic ovarian syndrome, hypothalamic amenorrhoea, endometriosis, tubal infertility (pelvic inflammatory disease), unexplained infertility, medications, oligoazoospermia
Less common but 'important not to miss'
thyroid dysfunction, prolactinoma, primary ovarian failure, panhypopituitarism
Uncommon
congenital adrenal hyperplasia, craniopharyngioma, empty sella syndrome, Asherman syndrome, Kallman's syndrome, azoospermia
Related Scenarios
[Amenorrhea]