Preparatory Mindset
Infertility affects ~10-15% of couples and is a structured, protocol-driven topic — perfect for exams. The mindset: define it (1 year unprotected intercourse without conception), evaluate both partners systematically, and choose the treatment by cause. The diagnostic workup follows a four-lane highway: ovulation (does she ovulate?), tubes (are they patent?), sperm (is he normal?), uterus (is the cavity normal?). Treatment ladder: lifestyle + timed intercourse → ovulation induction (clomiphene/letrozole) + IUI → IVF/ICSI. The most important exam messages: male factor accounts for ~40% of cases (evaluate the man FIRST — semen analysis is cheap and non-invasive), tubal disease is the main female mechanical cause, and IVF (in vitro fertilisation) with ICSI (intracytoplasmic sperm injection) is the definitive treatment for tubal, severe male factor, and failed other therapies.
Core Concepts
1. Definitions
| Term | Definition |
|---|---|
| Infertility | No pregnancy after 1 year of unprotected intercourse (6 months if woman >35) |
| Primary infertility | Never conceived |
| Secondary infertility | Previous pregnancy but now unable to conceive |
Epidemiology: ~10-15% of couples; incidence increases with age (especially female >35); ~40% of cases involve male factor, ~40% female factor, ~20% combined/unexplained.
Causes — the four lanes:
| Lane | Female | Male |
|---|---|---|
| Ovulation | Anovulation/oligo-ovulation (PCOS most common), hypothalamic, premature ovarian insufficiency, thyroid/prolactin | — |
| Tubal/patency | Tubal occlusion (PID, chlamydia/gonorrhoea, endometriosis, previous ectopic, surgery), adhesions | — |
| Sperm | — | Oligo/azoospermia, astheno/teratozoospermia, obstruction, varicocele, hypogonadism |
| Uterus/cavity | Uterine fibroids (submucosal), polyp, septum, Asherman (adhesions) | — |
2. Evaluation — the workup
| Test | Female | Male |
|---|---|---|
| Ovulation | Menstrual history (regularity), mid-luteal serum progesterone (>30 nmol/L), ovulation prediction kits (LH), USS tracking; day-3 FSH/E2/AMH (ovarian reserve) | Semen analysis (×2) — volume, count (≥15 million/mL), motility (≥40% progressive), morphology (≥4% normal); antisperm antibodies; sperm penetration assay |
| Tubes/cavity | HSG (hysterosalpingography) — tubal patency + cavity; hyCoSy (USS contrast); hysteroscopy/laparoscopy + dye (gold standard for tubal + pelvic pathology) | — |
| Hormones | FSH, LH, estradiol, AMH (day 3); prolactin; TSH; testosterone (PCOS) | Testosterone, FSH/LH (hypogonadism); karyotype (azoospermia) |
Order of investigation: semen analysis + ovulation assessment + tubal patency (HSG) — in parallel, not sequentially, to reach a cause quickly.
3. Treatment — the ladder
| Step | Treatment | Indication |
|---|---|---|
| 1. Lifestyle + optimisation | Weight (BMI), smoking/alcohol cessation, folic acid, timing intercourse (fertile window ~day 12-13 in a 28-day cycle) | All couples |
| 2. Ovulation induction (OI) | Letrozole (first-line, preferred over clomiphene for PCOS) or clomiphene citrate (day 2-5, 5 days); monitor with USS + LH kits; gonadotrophins (FSH) if resistant; metformin adjunct in PCOS with insulin resistance | Anovulatory (PCOS, hypothalamic) |
| 3. Intrauterine insemination (IUI) | Sperm washing + insemination at ovulation; combined with OI | Mild male factor, unexplained, cervical factor |
| 4. IVF (in vitro fertilisation) | Controlled ovarian hyperstimulation (gonadotrophins + GnRH analogues) → oocyte retrieval → fertilisation (IVF or ICSI) → embryo transfer (fresh/frozen) → luteal support | Tubal occlusion (main), severe male factor, endometriosis, failed OI/IUI, unexplained, genetic screening |
| 5. ICSI | Direct sperm injection into oocyte | Severe male factor (low count/motility), previous failed fertilisation |
| 6. Third-party | Donor sperm/egg, surrogacy (regulations vary) | Azoospermia, premature ovarian insufficiency |
IVF success rates: ~30-40% per transfer (age-dependent, falls sharply >40); cumulative rates higher with frozen embryo transfers (FET).
Complications to counsel:
- OHSS (ovarian hyperstimulation syndrome) — abdominal distension, ascites, thromboembolism, renal impairment — risk with gonadotrophins; prevent with antagonist protocols + freeze-all.
- Multiple pregnancy (twin/triplet) — the biggest IVF risk — reduce by single embryo transfer (SET).
- Ectopic (higher in tubal disease), ovarian torsion, bleeding/infection after retrieval, psychological stress.
High-Yield Points
| Topic | Must-remember |
|---|---|
| Infertility definition | 1 year unprotected intercourse (6 mo if >35) |
| First-line male test | Semen analysis ×2 — male factor ~40% |
| Female lanes | Ovulation, tubes, uterus — HSG for tubal patency |
| PCOS ovulation induction | Letrozole first-line (clomiphene alternative) |
| Mid-luteal progesterone | >30 nmol/L confirms ovulation |
| Ovarian reserve | Day-3 FSH/E2/AMH |
| IVF main indication | Tubal occlusion |
| ICSI indication | Severe male factor |
| OHSS | Ascites, thrombosis — prevent (antagonist + freeze-all) |
| Multiple pregnancy | Biggest IVF risk — single embryo transfer |
| Unexplained infertility | 20% — OI + IUI then IVF |
Topic Summary
Infertility is evaluated by semen analysis (male first), ovulation assessment (mid-luteal progesterone), and tubal patency (HSG) — the four lanes. Treatment escalates from lifestyle → ovulation induction (letrozole/clomiphene) → IUI → IVF/ICSI. IVF is the definitive treatment for tubal disease, severe male factor, and failed OI/IUI; ICSI for severe male factor. Key complications to counsel: OHSS and multiple pregnancy (prevented by single embryo transfer). The exam takeaway: structured evaluation + cause-based treatment + honest counselling on success rates and risks.
LMCHK OSCE Practice — Couple with Difficulty Conceiving
Station setup: A 33-year-old woman and her 36-year-old partner present after 18 months of unprotected intercourse without conception. She has regular 28-day cycles, no dysmenorrhoea, no past surgery/PID. He has had two previous semen analyses showing count 5 million/mL (oligozoospermia), motility 20%.
Candidate tasks (8 min):
- Establish the diagnosis: infertility (1 year + unprotected).
- Interpret the male factor — oligozoospermia + asthenozoospermia (WHO thresholds: count ≥15 M/mL, motility ≥40%).
- Outline the complete workup — confirm ovulation (mid-luteal progesterone), HSG (tubal patency), hormonal screen (FSH/LH/T, prolactin, karyotype if azoospermia), USS.
- Discuss treatment options by cause: if tubal patent + ovulating → IVF (with ICSI given severe male factor); ICSI directly addresses oligo/asthenozoospermia.
- Counsel on success rates (age-dependent, ~30-40% per transfer), risks (OHSS, multiple pregnancy — SET), and lifestyle optimisation (weight, smoking, alcohol, folic acid).
Key marking cues:
- Male factor recognised as the driver (does not blame the woman).
- Orders semen analysis first and correct WHO thresholds.
- Proposes IVF/ICSI appropriately.
- Counsels on success rates + OHSS + multiple pregnancy + SET.
- Maintains empathetic, non-judgmental communication — an OSCE station about a sensitive topic.