Essay 359

a. I would obtain a history from the couple. I would specifically ask about their method of trying to conceive. If the partner is HIV negative then they may be using an insemination method to prevent the risk of transmission of HIV to the partner. If the partner is HIV postive then I will ask about the frequency of unprotected intercourse. I will enquire about their jobs and if either of them is exposed to radiation or harmful chemicals which may explain their infertility. I will ask about any previous children either together or from previous partners to establish if they are presenting with primary or seconday infertility. This will also have an impact on their eligibility for NHS funded treatment as they need to have not live children from either partner to be eligible. I will ask the female partner specifically of any miscarriages, ectopic pregnancy, TOP or any successful pregnancy and mode of delivery (previous ectopic or caesarean complicted by pelvic abscess endometritis may suggest tubal blockage). I will obtain a menstrual history asking for her LMP, duration of cycle (oligomenorrhoea may suggest PCOS and need for andorgen hormone profile), dysmenorrhoea suggesting endometriosis which is associated with infertility. I will ask her about symptoms of hyper and hypthyroidism and past medical history of diabetes, or hypertension. I will obtain a sexual history asking if she had pelvic inflammatory disease in the past suggesting blocked tubes. I will enquire about her current medications which may need altering if they are deemed to be teratogenic. I will ask if either partner smokes or drinks alcohol as this is associated with infertility. I will aslk the partner about any medical problems such as diabetes, hypertension, inflammatory bowel disease which can have implications on his sperm quality especially if he is on medication. I will ask him if he had any mumps in the past or any genital/abdominal surgery which may have affected his sperm quality

b. IVF is an option for this couple especially if the partner is HIV negative. IVF will reduce the risk of transmission of HIV to the partner avoiding the need to have unprotected intercourse or use insemination techniques at home where the sperm had not been washed. The success rates for IVF in her age group are around 20%. The low success rate may have a psychological impact on the couple if it fails and they will need support with counsellors in the ACU. HIV and its implications on the future pregancy need to be considered when deciding about the role of IVF in this couple. The couple needs to understand there is a risk of transmission to the fetus of 2-3% if mother is treated and 20-30% if untreated and breastfeeds. She will need consultant antenatal care and be compliant with medication. IVF is an invasive procedure requiring sedation for egg retreival. There are risks associated with the procedure of egg retreival such as injury to the iliac vessels and bowel injury, risk of infection and risk of ovariann hyperstimulation syndrome all which could be potentially life threatening. She is also at a higher risk of having an ectopic pregnacy and a multiple pregnancy if 2 embryos are transferred. In addition IVF is expensive. If the couple is elgible for NHS funded treatment, some PCT trusts only fund one cycle of IVF and any further attempts need to be self funded which can be an economical burden to the couple. IVF may not be the most appropriate first line treatment for this couple especially if they are eligible for NHS funded treatment. Intrauterine insemination (IUI) with or without ovarian stimulation has a high success rate in patients with unexplained infertility and is associated with minimal risks and may be more cost effective.  

A 33 year old woman and her 40 year old partner have been referred to the fertility clinic because they have been trying for a pregnancy for 3 years. The woman is known to be HIV positive.

(a) Discuss the information you would obtain from the history [12 marks]. 

I will take history in sensitive manner and provide evidence based written informatin to both patient and partner with documentation in notes all througout history, examination and during investigations.

Menstrual pattern details blood flow, cycle length , interval, duaration of bleed ,

complaints like menorrhagia, dymenorrhea, dyparenuia and infetility [endometriosis and adenomyosis],  

oligomenorrhea, hirsutism, acne, acanthosis nigricans, hair loss [ most common cause pcos]

 regularity, pain, flooding, extra precautions during period with pads, tampoons, shorter cycle lenght and bleeding heavily, any pressure symptoms with details about water works and bowel[ fibroid].

Headache, vision problems, galactorrhea[ high prolactin ] weight gain, menorrhagia, oligomenorrhea, intolerance to cold, fatigue [hypothyroidism]. decrease libido in males with increase prolactin.

sexual history in detials about frequncy of coitus[should be every 2-3 days], any problems with ejaculation, erectile dysfunction. Drug history, decrease

sensitive information relating to HIV ststus asked and investigation reviewed. General condition of patient, her latest CD 4 counts, viral load and treatment for HIV , HAART theray or no treatment. Detailed information given about vaccination required prior to pregnancy like measels, infulenza, hep b, varicella. consulatation with HIV physician reviewed, if not than appointment planned for futher treatment of HIV. 

history of smoking, alcohol, cafiienated beverages asked as they decrease fertility both in males and females. weight to be maintaned at bmi 19-29, comlplemetary therapies, recreational drugs. occupationa details , working where there is exposure to radiation, aniline dyes, stress.

past hisory of investigation like seminal analysis, tubal testing, or ovulation test. intake of ovulation induction drugs.

past surgical history like laparotomy, since there can be ahesions contibuting to  tubal infertility

contraception history, long acting inj contraception [ DMPA], may delay reversal of fertility, Condom usage since discordance in HIV status of partner, importance of testing and use of condom explained and also it decreases sexually transmitted infections.

past sexually transmitted infections, chronic pelvic pain, past treatment of infection with chlmadia or gonorrhea. smear history details asked and checked in notes, importance of annually cervical smear testing.

(b) No cause is identified for their sub-fertility. Critically evaluate the role of in-vitro fertilisation [8 marks]

i will explain patient pros and cons of in vitro fertilization and factors affecting it. Prior optimization of CD 4 counts, viral load, HAART theray, vaccinations and folic acid started prior to IVF treatment.

Referral to a higher fertilty centre approved by HFEA and where art is done, appointment should be made and patient reffered with detailed history and notes.

Since there is HIV dicordance it prevents infection to husband.

age 23-35 , 3 years of infertilty and unexplained infertlity are indications for IVF and live birth rates are 20% it decreases to 10 % at 39 years of age and at 6% above 40  yrs of age.

 hydroslapinx will require removal by surgery as it improves pregnancy rates.

associated male factor infertilty, azoospermia and tubal diasease will require IVF. not more than 2 embryos are tranferred. succes rates for IVF drops after 3 cycles if no pregnancy occurs in that 3 cycles.

need to stop smoking alcohol and beverage drink or to minimum as it hampers succes of IVF. support groups offered, cessation programmes informed and details given.

cycles stimulation wih clomiphene, gonadotophins, gnrh gonadotrophind long protocol,  has higher success rates as compared to unstimulate cycles unless it is contraindicated.

IVF has complications like multiple pregnancy (4%-8% )an also heterotopic pregnancy (1%), ecoptic pregnancy and implication of it during pregnancy. HFEA recommends not more than 2 embryos to be transferred, with latest recommendations of transferrinf only 1 embryo per cycle.Ovarian hyperstimulation syndromeion with gonadotrophins,  less with clomiphene due to stimulation and needing admission, analgesics might be intesive treatment and in rare cases surgery, is taken care of by ultrasound tracking of follicles.

pregnancy related complictaion like no increase rate of miscarriage as compared to general population, but increases rates of preterm pregnancy, antepartum haemorrhage and 2 fold increase rate of stillbirth [ perniatal mortlality]. Treatment with IVF is expesive to NHS system.

(a) Discuss the information you would obtain from the history [12 marks].

I need to obtain a history covering different aspects of the couple’s health. At first I’ll ask about the patient’s menstrual history, menarche and regularity of her periods. I’ll also enquire about any contraception she’s ever used and about previous pregnancies (even if they ended with miscarriage, terminations or ectopics). Sexual history, including STIs and PID is also important as well as any serious infections in the past or abdominal/pelvic surgeries. Similar history should be obtained from her partner as well.

History should also include dietary habbits (e.g. caffeine intake), smoking and the use of recreational substances (especially intravenously)

Regarding her HIV, I’ll enquire about the time of diagnosis, the possible mode of infection (if known) and her current status (i.e. viral load and if she’s on treatment or under medical care). We need to enquire about any symptoms that may suggest immune deficiency or complications due to inadequate treatment.

Moreover I’ll enquire about the methods they’ve been using to protect her partner from acquiring the infection. It’s important to know how well is the condition controlled.

Considering the main complain – infertility – I need to ask more details about their attempt for conception. So we need clear history on frequency of intercourse, the timing, any sexual dysfunction and if they sought medical help before.

 (b) No cause is identified for their sub-fertility. Critically evaluate the role of in-vitro fertilisation [8 marks].

In this couple’s situation it is obvious that assisted conception is an ideal method of help. Considering that all their investigations are normal and their long attempt for conception IVF is better for them than IUI. However, the NHS entry criteria are very strict and for couples that are not eligible then private treatment is going to be quite expensive.

IVF has the advantage of protecting the patient’s partner from acquiring the virus. However, there is always the risk of infection of the laboratory personnel who are dealing with the IVF. That’s one more reason why patients attempting for IVF need to be screened for blood-born viral infections. Considering her medical condition she may need to be referred to a unit where they would accept proceeding through IVF treatment safely.

There is a possibility of 1-2%, while the patient is under antiretrovirals, that the infection is passed to the fetus. It is, also, important for the couple to understand that IVF is not always successful and they might need more than one cycle of a trial.(b) No cause is identified for their sub-fertility. Critically evaluate the role of in-vitro fertilisation [8 marks].

The process itself is lengthy and sometimes stressful as she’ll need to be on hormonal treatment, have frequent ultrasounds and then going through the process of egg retrieval.

Presence of serious pelvic inflamatory pathology like PID or hydro/pyosalpinges decreases the chances of IVF success. Additionally, smoking, alcohol consumption and use of drugs may still have a negative impact on the pregnancy success.

IVF also carries risks like ovarian hyperstimulation sundrome (OHSS) and that of multiple pregnancies. OHSS may be of a serious impact on the patients health, while multiple pregnancies carry many risks including those of miscarriage, fetal anomalies and preterm birth.

Qn: A 33 year old woman and her 40 year old partner have been referred to the fertility clinic because they have been trying for a pregnancy for 3 years. The woman is known to be HIV positive. (a) Discuss the information you would obtain from the history [12 marks]. (b) No cause is identified for their sub-fertility. Critically evaluate the role of in-vitro fertilisation [8 marks].

a)History I will obtain from the woman will include her current status and treatment for HIV - her latest CD4 count and viral load; if she has low CD4 counts and/or high viral loads, there is a higher risk of HIV transmission to her fetus if she gets pregnant and she should be advised against pregnancy till viral loads are undetectable. I will ask if she is on any anti-retroviral therapy and Pneumocystis carinii pneumonia (PCP) prophylaxis e.g. co-trimoxazole. If she is already taking HAART and/or PCP prophylaxis before pregnancy should not discontinue their medication . However ideally couples should be advised to delay conception until prophylaxis against PCP is no longer required and any opportunistic infections have been treated. I will also ask if she has any other co-infections especially Hepatitis C as the risk of transmission to the fetus is higher if she has both HIV and Hepatitis C infections.

I will ask about the regularity of her periods and last menstrual period. Oligomenorrhoea may suggest oligo- or anovulation.

I will also enquire about her past obstetrics history - previous successful pregnancies will suggest better chances of her achieving a further successful pregnancy. Previous recurrent uterine instrumentation for termination of pregnancy or miscarriage may also affect her fertility. I will ask if she has any history of pelvic inflammatory disease, Chlamydia infections or endometriosis which may adversely affect her chances of getting pregnant. I will also ask her about her contraceptive methods - if they are using condoms to prevent HIV transmission to her partner. Social history such as recreational drug abuse, alcohol intake and smoking should be obtained as these have possible adverse effects on fertility and pregnancy. I will also check her smear history - if it has been done within the last year. I will also check if she has any previous rubella vaccine immunisation.

I will ask her partner if he has a history of mumps orchitis or any previous testicular surgeries which may affect spermatogenesis. I will also enquire about his occupation - if he is exposed to any chemicals which may affect his sperm quality/production. I will ask him if he smokes or takes any recreational drugs.

b) The advantages of in-vitro fertilisation for this couple include reducing risk of HIV transmission to her partner. If there are existing co-infections such as Hepatitis C, the risk of transmission to the partner will also be reduced.

However, the main disadvantages are that of relatively low success rates of IVF (about 15-20%). IVF also requires the woman to undergo ovarian stimulation with GnRH agonists which has side effects of ovarian hyperstimulation, nausea, bloating. GnRH agonists need to be administered subcutaneously and require close monitoring with frequent follow up visits and ultrasound examination. There is a high risk of multiple pregnancies with their associated pregnancy complications of preterm deliveries, hypertensive disorders, fetal anomalies, especially if 2-3 embryos are transferred. IVF is also expensive and may not be fully funded by NHS.

Although the risk of transmission to the partner is reduced, risks of transmission of the fetus in pregnancy is not totally avoided. Furthermore, other fertility treatments such as intrauterine insemination of the partner's sperm into the woman are available with similar pregnancy rates.

(a)

The couple should be seen together in a specialised infertility clinic and history asked in a sensitive approach.

I would ask the woman about her menstrual history. Irregular menses, oligo/amenorrhoea suggest polycystic ovarian syndrome. Dysmenorrhoea suggests endometriosis.

I would check with her if she had any previous pregnancies as previous successful pregnancies are associated with better IVF outcomes.

For drug history, I would ask if she was previously on any contraception. IM depot provera is associated with a delay in return of fertility. Also, I would check if she was previously vaccinated for Rubella.

I would enquire if she had any history of pelvic inflammatory disease as it can cause tubal occlusion or any dyspareunia which suggests endometriosis.

I would check if she is on any long term medication which may affect her menstrual cycle, for example, antipsychotic medications causing hyperprolactinaemia and thus amenorrhoea, or chemotherapy for non-hodgekin lymphoma which is associated with AIDS.

I would like to ask if she had other medical problems such as autoimmune disease which may cause premature ovarian failure. As she is HIV positive, I would like to know how well controlled her disease is by asking for her latest CD 4 counts and viral loads, the type of HAART she is on and if she needed any pneumocystis carinii prophylaxis.

I would ask if she had any surgeries done to the tubes or uterus such as salpingectomies which may be the cause of her infertility.

Lastly, I would ask in her social history if she consumes alcohol, recreational drugs or smokes as these can contribute to infertility. Stress at work or home would be sought for as well.

For the man, I would check if he has any medical problems such as diabetes and hypertension as diabetes can cause retrograde ejaculation. History of mumps or orchitis should be asked as they affect testicular function.

I would ask if he had any previous testicular injuries or surgeries that may affect testicular function.

I would ask for any problems as such gynaecomastia or small testis which may suggest Kleinfelter’s syndrome.

Lastly, I would ask in his social history if he consumes alcohol, recreational drugs or smokes as these can contribute to infertility. Stress at work or home and wearing of tight pants would be sought for as well.

I would enquire about the frequency of sexual intercourse and if any condom was used. I would also ask about problems with erection, ejaculation and penetration.

(b)

An advantage of IVF is the avoidance of sexual intercourse which decreased the risk of transmission of HIV to the man.

Another advantage is that the timing of IVF can be planned at a time when the woman has minimal complications such as pneumocystis carinii pneumonia or non-Hodgekin’s lymphoma, as she may not be able to withstand the stress of IVF when she is sick and immunocompromised.

A disadvantage is that the woman would have to go through a series of hormonal injections for pituitary suppression and ovulation induction which predisposes her to the risk of OHSS. And she will need regular ultrasound follow up for follicular tracking.

Oocyte retrieval is associated with risks of bleeding, infection, bowel injury and discomfort.

In IVF, there is a risk of inadequate number of oocytes retrieved, failure of fertilisation, failure to grow into viable embryos as well as failure of embryo implantation, which means that she would have to go through another cycle all over again.

The success rates of IVF varies in different centers but range between 15-20%. IVF is expensive and psychologically straining for the woman and her partner.

Even if she gets pregnant, there is a risk of vertical transmission to her baby as well.

1. The aim of taking a detailed history from the couple is to find the cause of their subfertility.

Enquiry is made whether the infertility is primary or secondary as chances of success are higher if previous conceptions.If secondary infertility, details of previous pregnancies are taken (miscarriages,ectopic or term pregnancy).Ask if the pregnancies were spontaneous or with assisted conception.Time interval from the last conception is enquired.

Enquiry is made about any previous investigationslike semen analysis,ovulation and tubal patency.Treatment received in past are reviewed.

Menstrual history regarding LMP,cycle regularity and duration of bleeding is taken.Any associated symptoms like dysmenorrhoea, dyspareunia  and menorrhagia are asked.

History of Pap smear is taken.

Previous contraceptive history is taken.

Woman is asked about pelvic inflammatory disease in the past as it may lead to subfertility. Husband is enquired about infection like mumps or tuberculosis.

Surgeries like tubal sterilization or reversal  are asked. In the male partner ask about surgeries for undescended testis,inguinal hernia or varicocele.Drugs like sulfasalazine or cimetidine are associated with subfertility.

Frequency and timing of sexual intercourse is enquired.Method adopted to reduce HIV transmission risk is asked.

Occpation leading to long time away from home or other occupational hazards are enquired.

History is taken regarding smoking, alcohol, drug abuse and obesity(BMI)

History is taken from the woman  in a sensitive manner regarding the duration of HIV.

Severity of the disease is assessed from her reports of viral load and CD4 count.

Visits to HIV specialist and retroviral therapy are enquired

Risk factors associated with high risk of vertical transmission are noted.

Rubella immunity and other vaccination history is taken.

1. IVF has a role in the treatment of couples with subfertility of more than 3 year duration particularly in this case as the male partner is already 40 years of age. Chances of successful pregnancy decline with increasing age.

However,IVF is associated with financial and psychological implications.IVF is not funded by the NHS and is an expensive treatment.

Frequent visits are needed for  cycle stimulation,follicular tracking and  oocyte retrieval .This may be associated with stress.

There are increased risks of complication due to laparoscpic  oocyte retrieval and the risk of ovarian hyperstimulation syndrome. IVF is associated with increased risk of ectopic and multiple pregnancy.

Risk of HIV transmission to the partner is reduced.

The success rate of IVF is 15-20% .

Considering the low success rate and high cost, intrauterine insemination may be a more cost effective option in this case of unexplained infertility.Couple’s wish should be considered.

1. I will ask the women the duration she is aware that she is HIV positive and whether she and her partner is aware of the implication of her status on the coming children. Her partner status should be confirmed about the HIV if not done. They should be dealt in sensitive and supportive manner and their confidentiality should be maintained all the time.

Regarding the women she should be asked about her menstrual history –menarche ,LMP ,amount and duration of flow as irregular cycle associated with anovulation. She should be asked about whether any pregnancy event before , their mode of deliveries and out come including miscarriage and induced abortion whether it was medical or surgical management . she should be asked about weight gain, cold intolrence hirsutism and galactorrohea . she should be asked about vaginal discharge, pain and dyparunia or PID in the past and any treatment taken for that. She should be asked about her sexual history including frequency of intercourse, superficial or deep dysparunia and duration of cohabitation .  she should be assessed for the risk of  other STI by asking the number of sexual partner or any change in sexual partner or practicing safer sex. She should be asked about contraceptive history about the method and when she last stopped because some contraception like DMPA may delay in return of fertility up to two years.

she should be enquired about her life style ,smoking alchohal, coffee and any drug abuse.

She should be enquired about any medical comorbidities like diabetes, hypertension ,epilepsy ,mental health problem and treatment taking for that as these comorbidites and their treatment may be associates with subfertility.

She should be asked about any surgery she has undergone for any disease including gynnaecological problem as pelvic adheshion may reduce her fertility.

She should be asked about drug whether she is taking  prescribed or over the counter .

I will ask her whether she is taking any drug for her HIV status and following HIV physician for herself, if not she should be advised to follow and appropriate referral should be made to know her viral load and need of treatment.

She should be enquired about her rubella status, any blood born  viral infection like HBV,HBC and intake of prepregnancy folic acid ,it may need to modify her some drug intake if it is found teratogenic.

Male partner should be advised to check his status for HIV  and other blood born infection if not done. He should be enquired about his profession and life style as certain profession like working in high temperature environment will reduce the sperm count. He should be asked about smoking ,  alchohal ,coffee and other drug intake as these Factors  decrease the sperm count.

He should be also enquired about any medical comorbidites he is suffering and treatment taken for that. He should be asked about any trauma, accident and surgery over spinal cord or not as they may influence his sexual function . he should be also enquired about any surgery  over the genital area done or not like orchidopexy, hernioraphy.

He should be asked about sexual problem like premature ejaculation ,retrograde ejaculation and any other sexual dysfunction.

They should be asked about any treatment or investigation done for her this issue before if yes then I would like to see the report.

2.I will explain them that in case of unexplain infertility the couple conceive with reassurance and support without any treatment in next one to two years.

She should be advised to optimize her health before going for any fertility treatment like in her case she should be advise to follow HIV physician about for her HIV condition ,viral load cd4 count and to start treatment for herself to optimize her viral load before going for pregnancy. Her medication should be revised to avoid any teratogenic effect on the fetus. As  HARRT in first trimester associated with teratogenesis.

She should advise to modify her life style like stop smoking  ,alchohal, to do exercise and weight reduction if her BMI is high.

 If couple doesn’t want to wait and anxious about conception then they go for other first line of treatment like ovulation induction by clomiphen citrate for the 12 month if she didn’t conceive in first 6 month it can be combine with IUI. They can be advised for the stimulation with gonadotrophins with IUI .All the above mode of treatment have same out come as expectant management in case of unexplian cases.

They should advise that IVF has about 20%success rate associated with multiple pregnancy ,ovarian hyperstimulation ,increase monitoring and costly also, and cost of repeated IVF is not be taken by NHS.

In  her case if her partner is HIV negative  then IVF  will reduce the transmission to his partner however IUI around the time of ovulation stimulated or unstimulated cycle can be also be tried.

In case of IVF they can choose to have donar egg if they want to reduce the risk of HIV transmission to her fetus, although the risk of perinatal transmission is there which can be further reduced by HARRT or surrogacy. in case of IVF they can have oppurtunity to have preimplantation genetic diagnosis if they have any hereditary disease in family.

IVF has lots of financial ,emotional and social implication and in her case health care professional and laboratory should take universal precaution to minimize the transmission while handling body fluids.

 Written Information leaflet should he given ,and further appointment to disscuss any query.

A 33 year old woman and her 40 year old partner have been referred to the fertility clinic because they have been trying for a pregnancy for 3 years. The woman is known to be HIV positive. (a) Discuss the information you would obtain from the history [12 marks]. (b) No cause is identified for their sub-fertility. Critically evaluate the role of in-vitro fertilisation [8 marks].

A                  From the woman, I would ask about details of any pregnancies (successful or otherwise ) in this liaison or previous relationships; I would want to know if there were any difficulties encountered getting pregnant or treatment needed to achieve pregnancy. I would also ask about subsequent fertility (if known ) of any former partners. I would ask the man for details about previous evidence of fertility in this and past relationships.  I would enquire about the duration of past infertility and the time to achieve previous pregnancies (if any)

From the woman, I would take a full menstrual history which would include LMP, information on frequency / regularity and length as well as any associated problems such as dysmenorrhoea  and cyclical pain and heavy menstrual loss. Regular cyclical pain could suggest endometriosis  where as irregular periods and bouts of amenorrhoea all suggest anovulation.

I would ask the woman about length  and type of any previous contraception use, particularly long acting progestogens such as depo provera which can be followed by a period of delay in resumption of ovulation. I would ask the man if he has had vasectomy and reversal of the procedure

I would ask about previous sexually transmitted diseases in both the man and the woman, ask about previous PID and treatment. Its also important to know that smears ar up to date especially with co-existing HIV

I would want to know about medical conditions in the woman and man that can reduce fertility such as thyroids disease in the woman or a history of mumps in the man. Even common prescription medications such as antidepressants can have a negative effect on fertility so a thorough drug history is essential. It is important to ask about previous pelvic surgery in the woman and this may have resulted in reduced fertility secondary to adhesions. In particular in this case, I would also want to know the man’s HIV status, and more information on the disease severity of the woman. I would want to know when she was diagnosed,  the medications she is taking, her most recent CD4 count and her most recent viral load.

Its important to know the occupation of the couple, especially the male as exposure to high temperatures, chemical and ionising radiation can all affect sperm production. If either partner works away from home, this may affect the frequency of coitus. It is also important to ask about smoking, alcohol and caffeine consumption and recreational drug use, all of which have been shown to reduce fertility.

Finally I would sensitively enquire about the frequency of coitus and ask about associated problems such as dyspareunia, erectile and ejaculatory dysfunction.

B        Treatment of prolonged unexplained fertility can undertaken with IVF. In this case where the woman is HIV positive, IVF will remove the risk of unprotected intercourse if the husband is HIV negative, its also likely to be more successful than times artificial insemination in this case.

IVF  has a success rate of 30-40% (higher if she has had previous successful pregnancies) which is higher than IUI (15%).

 It is important to take account of the welfare of the potential child. Even in this case where the woman is HIV positive vertical transmission can be reduced to less than 1% if the woman is taking HAART and avoids breast feeding. It should be noted however that very little is known on the effect of invasive procedures such as egg retrieval on the effect of vertical transmission.

There are disadvantages though, IVF is expensive if it is not funded and there is a great deal of variability in funding from different PCTs.

Not all fertility centres cater for the storage of potentially HIV infected gametes and the couple may have to travel long distances to access a centre that does.

There is also the increased risk of multiple pregnancy and associated morbidity associated with multiple pregnancies.

A 33 year old woman and her 40 year old partner have been referred to the fertility clinic because they have been trying for a pregnancy for 3 years. The woman is known to be HIV positive. (a) Discuss the information you would obtain from the history [12 marks]. (b) No cause is identified for their sub-fertility. Critically evaluate the role of in-vitro fertilisation [8 marks].

Regarding her fertility ,menstrual history is important including it,s regularity, amount,presence of severe dysmenorrhoea also her sexual history(freuency,dysparunea, protected sex by condom or not

presence of any STD other than the HIV

history of the previous trials (by unprotected sex or by woman self insimination ,were they  recieved induction or not, and what was her ovulation status,what were the results of tubal patency test and seminal analysis test (if they had been done)

Regarding her HIV status,whether on treatment or not and what type of treatment , what was the last result regaridng viral copies/ml

B/ so this is unexplain infertility

they should be advice to undergo the invitro ferilization,  after her viral load less than 50 copies/ml

this will help in avoiding unprotected sex so reduce risk of transmission to the partner, and the ovum will be treated with anti retroviral treatment  so decrease the risk of HIV transmission to the fetus.but it is expensive and not covered by the national health system, and may result in multiple  pregnancy that in turn may increase the operative deliveries and hence the maternal to child HIV transmission

1) It is important to assess if this is primary or secondary infertility therefore a history of previous pregnancies including miscarriages for each partner should be asked for. The woman's menstrual history is important: if she has a regular cycle it will imply that she is most likely ovulating. The frequency of intercourse should be elicited. Enquire about various risk factors of infertility such as smoking, alcohol, drug abuse including metabolic steroids (especially for the male partner). Also identify the occupation of each partner as this could imply possibe exposure to occupational hazards that could adversely affect fertility. A past medical history of the woman about pelvic inflammatory disease and previous abdominal operations may indicate a tubal factor of her infertility. Also elicit any symptoms such as galactorhoea that could indicate hyperprolactinaemia and symptoms such as cold intolerance, weight gain, lethargy that could indicate thyroid problems. Elicit some further information about the HIV status of the woman; the duration of her diagnosis, if she is on any current treatment and if her partner has been tested for HIV.  For the male partner, additional information regarding previous infections such as mumps or a history of trauma may indicate a cause of infertility. It is important to rule out any treatment for cancer in the past eg chemotherapy or radiotherapy as well as any procedure for permanent contraception such as sterilisation.

2) In-vitro fertilisation can be justified for this couple as they suffer from unexplained infertility for 3 years. IVF is generally more successful method of assisted conception compared to intrauterine insemination, and it's success is dependent on maternal age, the duration of infertility and  the history of any previous pregnancies. In this particular couple another advantage of IVF is that it will reduce the risk of transmission of HIV to the male partner. If the couple are known to have any inherited condition, pre-implantation genetic diagnosis could be offered to reduce the risk of transmitting the gene to their offspring. On the other hand, IVF is associated with significant stress for the couple due to the muptiple tests and procedures that they undergo so regular support is essential. IVF for this couple may be an expensive option especially if it will not be funded in case they do not meet the appropriate criteria. There are risks associated with IVF such as ovarian hyperstimulation syndrome (1/3 of women undergoing IVF suffer from mild OHSS and 3-8% form moderate and severe OHSS), increased risk of ectopic pregnancy and risk of multiple pregnancy (unless only embryo is transferred). The couple should be aware of these risks and appropriate information in the form of leaflets should be given.  The risk of ovarian cancer is unknown after ovarian stimulation.

 (A) I would find out about her menstrual history, specifically asking for her last menstrual period and the regularity of her periods. If her cycles are long and irregular, it will signify anovulation. If she has dysmenorrhoea, it might suggest endometriosis.  I would ask her about any other medical illnesses like history of chronic illnesses, or complications of HIV which could affect fertility. If she had any history of other sexually transmitted disease like Chlamydia and hepatitis C. If she had any abdominal surgeries previously which could cause peritubal adhesions. I would ask about her HIV control and the current medications she is on now to ascertain if this is a good time to start fertility treatment. I would check if she is on prophylaxis for pneumocystis carinii because bactrim can increase the risk of neural tube defect in the fetus.

I would ask her partner about his HIV status and what precautions they take to prevent spread if he is HIV negative. I would also ask when was the last time he checked his HIV status. I would ask if he has any chronic medical condition, surgeries, history of mumps orchitis or testicular injury in the past which can affect spermatogenesis.

I would ask both her and her partner if they had any pregnancies before with each other or other partners to determine if this is primary or secondary subfertility. I would find out about their occupation to check if they are exposed to any chemicals or extreme heat which can affect the fertility. I would find out if they have any family history of infertility or premature ovarian failure.  I would find out if they smoke, drink alcohol excessively or use any drugs of abuse. I would find about their frequency of coitus and if they have any problems like dyspareunia or impotence.

(B) IVF is useful especially if her partner is HIV negative because it eliminates the chance of transmission during sexual intercourse. IVF will improve their chance of pregnancy because they have been subfertile for 3 years, albeit the success rate of IVF is only 15-20%. Another advantage is that the timing of IVF can be controlled to be done at a time when the patient’s viral load is low. The disadvantage of IVF would be subjecting the patient to the risk of ovarian hyperstimulation and oocyte retrieval. There is also a risk of multiple pregnancies but it can be decreased by only transferring 1 embryo at a time. IVF cannot eliminate the risk of vertical transmission to the fetus but it can be minimized to less than 1% with the use of medications during pregnancy and keeping the viral load to a minimum. The cost and psychological stress with IVF will be high. We need to consider other methods like intrauterine insemination with or without ovulation induction as they are less invasive than IVF, and they can improve the pregnancy rate in patients with unexplained causes of subfertility.

A 33 year old woman and her 40 year old partner have been referred to the fertility clinic because they have been trying for a pregnancy for 3 years. The woman is known to be HIV positive. (a) Discuss the information you would obtain from the history [12 marks]. (b) No cause is identified for their sub-fertility. Critically evaluate the role of in-vitro fertilisation [8 marks].

a. Female history will include LMP, menstrual cycle regularity, history of menorrhagia, dysmenorrhia and when her last smear. In the sexual history I will explore previous sexual transmitted infections, dysperunia or post coital bleeding.  In her obstetric history I will enquire about previous pregnancies, miscarriages, ectopic pregnancies.   I will explore previous medical history such has PCOS, DM, hypertension, AIDs and infections such as Heptatitis B&C and rubella status.  In the drug history I will explore antiretroviral medication,other medications she is currently taking and allergies.  I will enquire about any family history of thromboembolism, oncology and history of infertility.  In her social history I will ask about smoking, alcohol and drug abuse history and occupation to assess patients social class.

In her specific questioning about HIV status I will enquire about current follow up, recent hopsital admissions, CD4 count and viral load if known.

In the male history I will explore previous children or pregnancies with the current partner and previous partners.  I will enquire about his past medical history infections such has measles,STD, any exposure to radiation and his current HIV status.  In his drug history identify any medications and allergies.  I will explore his social history such has smoking, alcohol and drug abuse.

From the couple I will enquire about frequency of sexual intercourse, any concerns about sexual intercourse such has dysparunia, postcoital bleeding. vaginal or penile discharge or erectile dysfuntion or premature ejaculation.  Any history of contraception in the past.

b,

Critically evaluate the role of in-vitro fertilisation [8 marks]

Unexplained infertility is a common cause of infertility.  Having knowing that the female patient is HIV positive the recommended option of IVF is  toreduce the chance of HIV transmission and also increase chance of pregnancy.  IVF will have the opportunity to  select oocyte and sperm prior to implantation.  avoiding timely sexual intercourse will reduce and assisted reproduction is safer in serodiscordant HIV women.  The success of IVF falls with increasing maternal age.  Life style factors such as alcohol consumption, smoking, extremes of BMI and increased caffeine consumption reduces the success of IVF.  The embryo transfer can take place when the patient viral load is low reducing the chance of transmission and her antiretrovirals can be timed with her gestation to reduce the transmission risk to the fetus further

IVF pregnancies are high risk pregnancies.  There is increased risk of ectopic pregnancies, ovarian hyperstimulation and risk of mulitple pregnancies.  Also though the single embryo transfer approach is an attempt to reduce the risk of IVF. The antenatal period of IVF pregnancies is high risk as the pregnancy has increased risk of developing maternal complication such as eclampsia, increased maternal and fetal morbidity.

A 33 year old woman and her 40 year old partner have been referred to the fertility clinic because they have been trying for a pregnancy for 3 years. The woman is known to be HIV positive. (a) Discuss the information you would obtain from the history [12 marks]. (b) No cause is identified for their sub-fertility. Critically evaluate the role of in-vitro fertilisation [8 marks]. 

The couple should be seen together. A detailed history should be taken from the woman including menstrual history, any previous pregnancies and any gynaecological procedures. A smear history should be obtained. Further information with regards to her HIV such as medication and complications should be discussed. A full past and present medical and surgical history should be taken looking for other factors associated with infertility such as thyroid disturbance, PCOS, endometriosis, PID or pelvic surgery. A drug history is necessary in particular NSAIDs can reduce fertility. A smoking and alcohol history should be taken from the couple.

The man should be asked about if he has ever farthered a pregnancy. A detailed past and current medical, surgical and drug history should be taken looking in particular for trauma to the testis, mumps, undescended testis, testicular surgery, or drugs that may cause azoospermia such as anabolic steroids and sulfasalazine. A family history is important for hereditary conditions such as fragile X.

It is important to ask the couple about how frequently they are having intercourse and if they are using barrier methods of contraception to reduce the risk of transmission of HIV.

IVF has strict criteria. In the case of unexplained fertility IVF is an appropriate treatment if it is acceptable to the couple. Success rates are variable and depend on factors such as maternal age, BMI and previous cycles. In this situation IVF will eliminate the risk of transmission of HIV to the male partner. In cases where the male partner is infected sperm can be washed to eliminate the risk of transmission to both the mum and the fetus however the risk of MTCT remains. The patients should be counselled before embarking on IVF due to the huge psychological implications. They should be aware of the risks it involves especially OHSS for the woman and multiple pregnancy, however in this situation single embryo transfer might be appropriate to reduce this risk. IVF funding is variable depending on the local PCT. IVF can be used in other circumstances such as same sex partnes and for those with a hereditary condition for whom PIGD can be performed,

 a)Full general gynaecological history of her last menstrual period,it's regularity,duration and frequency of her period . the amount of menstrual bleed,any assoociated dysmenorrhea or dysparunia,any history of inetermenstrual bleeding or post coital bleeding.history of any contraception used during the 3 yrs and it's duration.history of smoking,duration and number of cigarettes as well as alcohol consumption including amount and if it''s social or regular drinking. Obtain details   of her body mass index BMI ,any symptoms of polycystic ovaries of excessive hair growth or acne ,any galatorrhea milk coming from breast, any medical condition and those which may interfer with fertility of thyroid dysfuntion either hypo or hyper  thyroidism e.g easy fatigability,lethargy,loss of terminal hair ,cold intolerance for the former or  palpitation,tremors,eye manifestation heat intolerance for the latter.any surgical operation in the past or pelvic inflammatory dis.  PID which may contribute to adhesion formation and tubal factor infertility.

Review all the investigations which was done already in general gyne clinic including day 21 progesterone which good indicator of ovulation,FSH ,LH level ,thyroid function test as well as prolactin level ,Result of hysterosalpingography to test tubal patency if available.Her recent  partner semen anlaysis .

it's also important to enquire about any medication she is or she had on Folic acid,Ovulation induction treatment clomifene citrate dosage and duration of usage,

As the woman is known HIV positive ,further enquiry about the male partner status of HIV any contact screening was done for him ,more personal history taken in a sensitive way and ensuring patient privacy and confidentiality about frequency of sexual intercourse and if they are timing it for the period of maximum productivityp-ovulation time.

b) IFV will certainly decrease the chances of sexual transmission of HIV virus if male partner is HIV negative.HIV will allow for pre implantation diagnosis of any chromosomal abnormality . However IVF will put both p-artners under psycological stress because of chances of failure rate per cycle and the need for repeating IVF cycle several times.In addidtion IVF is an expensive modality of assisted reprouction technique which utilize time and medical manpower.

A 33 year old woman and her 40 year old partner have been referred to the fertility clinic because they have been trying for a pregnancy for 3 years. The woman is known to be HIV positive. (a) Discuss the information you would obtain from the history [12 marks]. (b) No cause is identified for their sub-fertility. Critically evaluate the role of in-vitro fertilization [8 marks].

a) First of all I will ask for menstrual history regarding frequency and regularity of menstrual cycle.as regular menstruation is indicator of ovulation. History of dysmenorrhea, dyspareunia and choric pelvic pain will be symptoms of endometriosis.

History regarding oligomenorrhea , hirsutism , weight gain and acne will point towards poly cystic ovarian syndrome. Any complaint of headache, visual symptoms and galactoria along with infertility will signify hyperprolactinemia.

Previous history of pelvic inflammatory disease or STIS is very important as these can affect future fertility.

Her past obstetric history is very important, as any conception and live birth is good factor for future conception. I will ask for her life style including alcohol intake as excessive alcohol intake can have effect on fertility. Smoking and usage of prescribed or over the counter drugs as they may affect fertility.

History of any contraception use and frequency of sexual intercourse will be as asked as 2-3 time unprotected intercourse can increase chances of pregnancy as compared to the intercourse at time of ovulation which can cause significant stress.

Use of tight underwear for male partner as increased scrotal temperature can effect semen quality. Occupational history is very important for both of them as there is evidence that some occupational hazard can affect fertility.

As above mentioned patient is HIV positive, so history regarding review by HIV physician ,control of disease, using HAART ,recent CD4 count and viral load is important. History about partner’s HIV status and measures for safe sex should be asked.

b) As woman is 32 years old and having three years of un-explained infertility, she is fitting into NICE criteria for offering three stimulated IVF cycles. She should be referred to center which has expertise and facilities to reduce risk of transmission of HIV infection.

In her age group success rate of IVF leading to live birth is around 10%.couple should attend fertility clinic together as psychological effect of test, invasive procedure and procedure outcome will affect both of them. Verbal, written and audio-visual information should be given along with information about support groups. Psychological support should be before during and after the investigation and procedure irrespective to outcome.

Ovulation induction is required by using clomiphene and gonadotropin and ultrasound egg tracking requires close monitoring which can be difficult for couple to cope with. Secondly complication of ovulation induction includes multiple pregnancy, and OHSS which if severe needs hospitalization and even intensive care.

Egg retrieval is an invasive procedure and requires conscious sedation analgesia, can have psychological impact on couple. Other complication of IVF include increase risk of miscarriage, increase risk of ectopic of heterogeneous pregnancy ,increase risk of pre-term delivery and pre-maturity are there. 

although IVF is having lots of risks but according to woman history she should be given chance for three stimulated IVF cycles.

Details of her disease should be obtained. Her medical record should be reviewed to see duration of the disease, severity of the condition from CD4 lymphocytes, viral load and history of infections. The drugs she is taking should be reviewed.

      Her obstetric history should be obtained including the number of children their modes of delivery and current health status. Pregnancies ending in termination, miscarriage or ectopic pregnancy should also be asked to assess risk of any uterine or tubal pathology.

      Past history of sexually transmitted diseases should be asked to assess the risk of tubal pathology.

      Menstrual history should be obtained to know the menarche, regularity of cycles, duration of period and amount of flow to assess the ovulatory status. Dysmenorrhea and dyspareunia are important to ask to know about the risk of endometriosis or pelvic inflammatory disease.

      History of contraception is important to obtain to assess the effect  on fertility as medroxyprogesterone is associated with delay in return of fertility and IUCD is associated with risk of PID and ectopic pregnancy in high risk population.

     History of any medical disorder is important to know the diseases which can compromise fertility such as diabetes, thyroid dysfunction, renal or liver disease. History of surgery is also important to know the likelihood of adhesions compromising the fertility.

       History of smoking, alcoholism and illicit drug use should also be obtained as these can also compromise fertility.

      Past history of treatments for fertility should be obtained and if she has obtained ovulation induction the record of investigations and treatment is important to know her response to ovulatory drugs and planning for future treatment.

     Details of male history should be obtained. Family history of relevant conditions such as cystic fibrosis and autoimmune conditions should be obtained.

     History of childhood problems such as undescended testis and major urogenital injury should be obtained.

     Medical disorders which can compromise fertility such as diabetes or renal dysfunction should be obtained. Drug history is also important as certain drugs can compromise male fertility.  

      History of sexually transmitted diseases including HIV is also important to obtain as it is important in aetiology and management. Sexual function for adequate erection and ejaculation should be inquired.

      Radiotherapy or chemotherapy can cause iatrogenic damage to testes therefore it should be inquired. Other causes of iatrogenic damage are surgical which should be explored such as repair for inguinal hernia or vasectomy.

       Life style factors such as occupational hazards, alcohol intake tobacco and drug abuse should also be noted.  

b)  In vitro fertilization is an option after three years of unexplained infertility. It is not the 1^st line of treatment.

      Ovulation induction with clomiphine citrate ‘an estrogen antagonist’ can be offered as first line of treatment but the unprotected intercourse should be limited to day of ovulation. The evidence of its effectiveness is modest. The benefit is thought to be due to correction of subtle defects in ovulatory function in follicular phase and ovulatory phase. The benefit of ovulation induction should be balanced against the risk of multiple pregnancy which is 10%.

       IUI with or without ovulation induction is an effective treatment. If husband is not infected it is safe also. It is cheaper and less invasive than IVF. 6 cycles of IUI should be offered before IVF can be offered, as it increases the chances of pregnancy. IUI with ovulation should not be offered.

       IVF is more invasive and expensive than IUI but is more effective option. It is safe also for her husband. It can circumvent most of the putative causes of unexplained infertility including ovarian dysfunction, cervical factors and problems with egg and sperm interaction. IVF also seems to have diagnostic value in identifying couples with fertilization failure. The live birth rate per cycle is 18%. Adverse effects of this procedure are multiple pregnancy and ovarian hyperstimulation syndrome. 

     The women need to be counseled about the pros and cons of this procedure. She should be informed about the interventions required to decrease the risk of transmission of infection to neonate which are HAART, possibility of delivery by caesarean section and avoidance of breast feeding. With all these interventions the risk of transmission to neonate is 2 to 3%.                  

A) Iwill ask 1st if there is previous pregnancy and it is outcome to determinate if this is primary or 2ry infertility,if both parents have another partener and if conceive before or not. menstural cycle,regularity,amount;dysmenorrhea to determine ovulatory cycle and pelvic pathology like endometriosis, menarche and 2ry sexuall characteristic abnomality for genetic and karyotype abnormalities.

occupation of the husband as working in area of chemicals or high tempreture affect spermatogensis, iwill ask also about sexuall intercourse ,frequency,good errection and ejaculation and if protected or not  

Hisory of STD inboth parents as this affect spermatognesis in male and tubal patency in female

History of PID in female (vaginal discharge,duration,treated or not). Iwill also ask about history male infection like orchitis,mumbs and history of testicular tortion undesending testis as these affect spermatogenisis.

iwill ask about history of previous operation in female like pelvic surgery, tubal surgery(affect tubal patency),uterine curretage(Asherman syndrome),

Iwill ask about history of thyroid ,adrenal disease as these affect ovulation 

Detailed history about HIV infection in the women,duration and if she is on HAART treatment.

B) IVF is suitable treatment for parents of un identified cause of ferility

If husband is HIV -ve intra cytoplasmic sperm injection can be use as this will avoid direct sexuall contact and reduce femal to male transimition

IF husband is HIV +ve sperm washing can be done following be intracytoplasmic  sperm injection ,this will reduce transmision of further HIV subtypes.and reduse fetal affection

IF women not on HAART it should be started before the procedure and viral load should be less than 50copies/ml

a) Detailed history should be taken from both partners. From female partner I would enquire about the age of menarche, regularity and pattern of menstrual cycle. History of oligomenorrhoea, acne, hirsutism and weight gain might be suggestive of polycystic ovarian syndrome. Mid cycle pain would suggest ovulation. I would also enquire about the symptoms of dysmenorrhea, menorrhagia as they may might point towards  endometriosis/ adenomyosis as likely cause. Symptoms of headache with galactorrhea might be suggestive of prolactinoma. I would also enquire about intolerance to cold/heat, as menstrual irregularities combined with these symptoms might point toward thyroid dysfunction. I would also ask about details of previous pregnancies if any, including any terminations, miscarriages, any obstetric interventions such as instrumental deliveries, dilatation and curettage. Previous history of STD, PID might suggest tubal factor as likely cause. I will also ask about previous medical and surgical history including any abdominal operations as adhesions might lead to tubal blockade. I will also ask in detail about her HIV control and if she is on HAART. I will enquire about recent viral load and CD4 count and pneumocystis prophylaxis. I will enquire if she is up-to-date with cervical smears and vaccination. Details about current or previous contraception be asked. Social history should include her smoking and drinking habits and type of job she does. Working with radiations, chemicals will impair her fertility.

I will then take history from male partner enquiring if he has any children. Past history of torsion, problems with erection and ejaculation, mumps is enquired. Surgical history including any abdominal operations, hernia repairs and testicular operations is asked. I will enquire about any drugs taken such as exogenous hormones, methotrexate, sulphasalazine as these will affect the sperm quality and quantity. Smoking and alcohol history should be taken. Enquiry about current job is important as dealing with strong chemicals and disinfectants can have adverse action on sperm quality. Couple should be asked about the frequency of sexual intercourse per week.  

b) IVF is a ray of hope for couples with fertility problems. . Success rate is quoted between 25-35%, however, various factors will affect this significantly. A strict NHS criteria for couple selection makes it impossible for some couples to have this treatment readily available and free of charge. Also at the moment only one cycle is offered on NHS; hence its failure causes great psychological and financial burden on couple.  Advanced maternal age not only decreases the quantity but also quality of oocytes making success rate much lower in women age above 40 years.  It is not only invasive and expensive but is associated with risk factors such as ovarian hyperstimulation syndrome and multiple pregnancy. Multiple attempts requiring stimulation of ovaries will put women at high risk of ovarian cancer in long term. Increased risk of ectopic pregnancies is also associated with this mode of treatment. Benefits in this couple will include lower chance of HIV transmission to partner and children.           Multiple embryos from one treatment can be frozen and used later on. However, failure of treatment can also have great psychological impact on couple. It is not offered by every hospital and referral to specialist assisted conception unit is required.  

The fertility care is couple centered care. For female, it would be important to establish the regularity of menstrual cycle and the last menstrual period.  With regular cycle the patient is more likely to be ovulating.  Next BMI would be important to know, both very low and very high BMI would affect the ovulation and also maintaining the pregnancy.  The history of smoking, alcohol intake and use of recreational drugs are important and again they would affect the fertility.  Whether this patient ever became pregnant in her life or had children with this partner or anyone else is useful to know about primary or secondary infertility.  If she had children, how long ago and the mode of delivery should be asked.  Any previous abdominal surgery and ovarian surgery are important to rule out scar or possible tubal block or reduced ovarian reserve may be the reason for the current issue.  With regard to HIV status, how it is being acquired whether sexually transmitted or occupational hazard in view of secondary effects on fertility due to pelvic infection.  How long does she know the diagnosis and treatment status and control status are important before planning the pregnancy, considering the welfare of the mum and baby.  Make sure that she is taking folic acid tablets and check the rubella status, chicken pox status and Hep B & C infection status are important again at the interest of welfare of the baby and the mum.  Make sure that she is having yearly cervical smears.  Need to know, whether partner is also infected with HIV or not.  If partner is not infected, then they should be using condoms in view of safe sexual health practice, then condoms would act as contraception which may be the reason.  On the other hand if partner is also affected, need to how he acquired and his control and treatment and CD4 level are important at the interest on welfare of them and the baby.  Need to know, whether he has ever fathered any children before and on any particular prescribed and non-prescribed medication which may affect his potent status.  Need to know whether he ever had sexually transmitted disease and any surgery to testicular area or history of mumps is important to rule out possible tubal block or reduced sperm counts.  Need to know clearly how they have been trying for pregnancy and how often are they trying; such as: 2-3 times a week minimum should be enquired.  It would be important, we work with HIV physician and the Patient’s general practioner to have better control of HIV status in addition to help with the fertility issue.

In vitro fertilization would be considered if the natural method and artificial insemination does not work.  It involves both financially expensive procedure and also more invasive than other above methods (natural / artificial insemination).  They may or may not get NHS funding depend on their location where they live, previous live children and female patient’s FSH status.  However, the female patient is less than 35years of age; her success with in vitro fertilization success rate is up to 30%, which is a very good one.  This procedure causes both physical and emotional strain / morbidity in the couple’s life.  Also there is high risk of ovarian hyper stimulation syndrome, aneuploidy, ectopic pregnancy risk and multiple pregnancy risk which puts the pregnancy as high pregnancy with high morbidity.   To reduce the risk of chromosomal anomalies, it is possible to do pre-implantation genetic diagnosis which may be useful if there is any familial medical disorder that they would like to avoid.  By doing, single embryo transfer one could reduce the multiple pregnancy risks.  In spite of all the risks involved, this may be the best option for this couple with unexplained infertility.

A)It would be important to see the couple together and obtain a history from both. In her history I enquire about her menstrual cycle, if it was irregular this may suggest PCOS especially if she also had signs of hyperandrogenism. If she was amenorrhic this could suggest hypothalamic amenorrhea related to low BMI or stress. Hyperprolactinamia can also cause cession of menstrual cycle so I would ask regarding galactoarrhea which is also associated. If she has dysmenorrhea this could suggest endometriosis and therefore tubal damage could be suspected. I would also ask regarding previous STI or PID as this can also cause tubal damage. I would ensure that she has had an up to date smear.

I would enquire if she has had previous gynaecogical surgery or investigations. As part of an obstetric history I would ask if she has had any previous pregnancies. I would obtain details of any previous deliveries, c sections can be associated with reduced fertility. If she had a PPH post delivery, sheenans would need to be excluded.

If she had any other medical problems such as thyroid disease or DM I would ask her regarding her control of these conditions as if uncontrolled they are associated with subfertility. I would enquire further about her HIV status would medications she takes and most recent viral load. If she has any co-infections such as Hep C as this would increase her chance of transmission of the virus if she did conceive. I would also ask regarding recent opportunitic infections and  would advise her to optimise her health prior to starting fertility treatment. I would check that she has been immunised for rubella and hep b.

I would ask her partner if he had had any children in any previous relationship. I would also enquire if he had suffered from any testicular injuries or  had orchitis in the past. I would ask a medical history and would exclude CF which is associated with infertility. Knowing his HIV status would help in advising further with fertility treatment.

Smoking and heavy alcohol intake can affect fertility so I would ask regarding this. Furthermore I would ask how many times a week they had SI.

B) IVF is expensive, invasive and has risks associated with the procedure such as bowel perforation at egg collection, OHSS as well as risks of ectopic and heterotopic pregnancy at the time of embryo transfer. 25% of IVF pregnancies are associated with multiple pregnancies which is associated with increased maternal morbidity and perinatal morbibity and mortality. There is also a significant psychological impact associated with IVF.

For this reason when treating unexplained subfertility there may be a role for other treatments first such as timed intrauterine insemination with or without ovulation induction. As this encourages natural conception it is associated with less risks and is more cost effective. If her partner was HIV positive the sperm could be washed prior to insemination to reduce the risk of a superinfection if he had a high viral load. If her partner was HIV negative, IUI would reduce his risk of contracting the infection.

If there was HIV discordance  IVF would also prevent her partner from contracting HIV. IVF also has slightly higher success rates compared with IUI and ovulation induction (25% compared with 20%.) However IVF should not be first line treatment in unexplained fertility due to the costs and associated complications.

A 33 year old woman and her 40 year old partner have been referred to the fertility clinic because they have been trying for a pregnancy for 3 years. The woman is known to be HIV positive. (a) Discuss the information you would obtain from the history [12 marks]. (b) No cause is identified for their sub-fertility. Critically evaluate the role of in-vitro fertilisation [8 marks].

A)    Detailed history has to be taken about menstrual pattern, sexual history, treatment history, HIV status of husband, and occupational history. I will ask about the regularity of cycles, flow of menses and any associated dysmenorrhea altogether with its severity. If woman is on HAART, is she provided with NHS funds or not. HIV status of husband has to be asked. If he is HIV+ and they are performing unprotected sex, ask about coital frequency, any associated dyapareunia, premature ejaculation, erectile dysfunction. If husband is HIV negative; what  technique are they using for conception. If insemination techniques with unwashed semen are used at home, whether properly performed or not.

Ask if couple is addicted to alcohol, smoking or recreational drugs, as this may effect the fertility. Ask about the treatment, couple had received in the past and investigations done. If any superovulation she had received, ART done or any surgery like tubal surgery, laparoscopy with chromopertubation or laparotomy for any fibroid.  Investigations like semen analysis, TVS for follicular tracking, serum progesterone or endometrial biopsy to see for ovulatory cycles had been done in the past. Ask them if any cause of infertility was told to them by past physician.

Ask about any chronic diseases couple is suffering from; like hypothyroidism, diabetes, hypertension, superimposed TB with HIV and on what treatment they are put on. Occupational history has to be asked as there may be exposure to dyes, radiation and excess heat as this may impair the fecundity. Detailed history has to be taken regarding the past medical and surgical history of husband. If any hernia, hydrocele or varicocele surgery had been done in the past.  If he had mumps orchitis, or any trauma of genitalia; must be enquired.

B)    When no cause is identified for their subfertility; couple has to be sensitively counselled. They should be explained that they have been categorized into unexplained infertility.  This category is most difficult to treat and often require ART. They should be explained of the pros and cons of IVF.  IVF is a costly option to them and NHS funds may not support it. The success rate of IVF is low only 30-40% and associated with complications like; multiple pregnancy, OHSS. They should be counseled that the future HIV status of neonate is difficult to predict and he may require HAART during infancy. So they must make proper informed decision after evaluating all the factors and if IVF is worth.  But in this case history of infertility is quite long of 3 years  and woman is HIV positive so IVF is justified. Due to the teratogenic effect of HAART, there may be defect at the level of fertilization, cleavage and implantation. Accordingly couple needs to be counseled and offered blastocyst transfer so as to bypass these steps.

[A]

Female partner will be asked about her previous conception i.e. with same partner or not. Frequency of intercourse, dyspareunia will be asked. History of previous genital infection will be asked. Her menstrual cycle pattern like oligomenhorea, dys menhorea, galctohrea, acne and hirstuism will be asked to exclude PCOD. She will be asked about DM, HTN and Chronic renal disease as these can cause an-ovulation. Sensitive approach will be done regarding her HIV status. She will be asked about HAART and consultation by HIV physician and her HIV physician opinion regarding her treatment for infertility. Her contraceptive methods, she used in the past, will be asked. Sensitive approach to the relationship and mental health will be enquired. History of infertility in the mother and sister will be asked.

Couple will be asked about the lifestyle, like smoking habit, alcohol intake and drug abuse. They will be asked about previous treatment of infertility like tubal test, semen analysis and ovulation induction.

Male partner will be asked about any previous children he has. He will be inquired about DM, HTN and any treatment he has taken. History of any surgery in relation to his genital tract will be asked. He will be asked about premature ejaculation and libido.

[B]

IVF is one of the treatments for unexplained infertility while considering the age of the female partner. Since she is HIV +ve so severity of the disease also comes under consideration before she will go under IVF treatment. If she is suitable for IVF then risk of HIV infection from mother to child will be minimized. Success rate of IVF with advanced age of female partner is less. Even she is HIV +ve still the IVF will be funded by NHS. Couple will be informed about success rate of IVF which is 25-30% per cycle. Risk related to IVF will be explained like ovulation induction by FSH injections can cause OHSS. Risk of ovum pickup will be explained by laproscopy. Risk of multiple pregnancy and ectopic pregnancy will be explained. Psychological issue in case of failed IVF will be considered.

Would take a menstrual history  lmp , cycle length,flow and regularity as  regular cycles are more likely to be ovulatory,

associated symptoms like menorrhagia, dysmenorrhoea, dyspareunia and chronic pelvic pain would indicate endometriosis.

menstrual disturbances like oligomenorrhea,amenorrhea, weight gain ,acne , hirsuitism will suggest  PCOS as a  cause of subfertility.

Any history of galactorrhea, visual disturbances , headache would suggest a pituitary cause.

Any h/o excessive weight loss , physical exercise and eating disorder would indicate a hypothalamic cause.

contraceptive history would help to know if patient is using contraception like condom for fear of transmitting the infection to her partner as this would delay fertility.

Any long acting reversible contraceptive methods like injectable progestogens were used as this may delay return of fertility.

in obstetric history I would ask about her parity , number of successful pregnancies,  as secondary infertility has higher success rate when treated by IVF.

Would enquire about other sexually transmitted infections  such as Heptatitis B&C and rubella status .

I will enquire if she is up-to-date with cervical smears and vaccination.

h/o pelvic inflammatory disease in the past and any treatment taken as distorted pelvic anatomy would lead to subfertiliy.

I will explore previous medical history such has DM and Hypertension or any other chronic disorder in either partner.

history of smoking/ alcohol and recreational drugs in both partners would be asked

Past surgical history of any abdominal and pelvic surgeries as adhesions may contribute to infertility.

Enquiry about past investigations like semen analysis in the male and tubal patency testing in the female would be made.

Reports would be looked into.

In the male past h/o infectious diseases like mumps ,  and  occupational details are taken. any exposure to radiation, any drugs like cimetidine,  sulpaphasalazine if taken will affect the sperm production.

From the couple a specific enquiry about lifestyle and sexual history will be taken.

 Sensitive  enquiry is made about frequency of coitus, as intercourse every 2 to 3 days optimises the chance of pregnancy.

 If there is any ejaculatory problem or erectile dysfunction to identify people who are less likely to concieve .

 any concerns about sexual intercourse such has dyspareunia, postcoital bleeding, vaginal or penile discharge  would be asked for.

In her specific questioning about HIV status I will adopt  a   sensitive approach .

would enquire about her  HIV status.   Detailed assessment of her latest CD 4 counts, viral load and treatment for HIV .

In the drug history I will explore, if she is receiving   antiretroviral medication, HAART  therapy  , any  other medications she is currently taking and drug allergies and if  she is receiving pneumocystis carinii prophylaxis as pregnancy is to be deferred till she completes the treatment.

Would enquire if she is up to date with her vaccinations. 

b)

 IVF would be ideal for this couple as it would enable the woman to conceive while minimizing chances of transmitting the infection to her husband.

In this woman the live birth rate for each IVF cycle  is approximately 30 to 35%.

Another advantage is that the timing of IVF can be controlled as it can  be done at a time when the patient’s viral load is low.

The disadvantage of IVF would be subjecting the patient to the risk of ovarian hyperstimulation which is a potentially serious complication with significant morbidity to the patient.    

Oocyte retrieval is associated with complications like  Intra-peritoneal bleeding , Pelvic infection ,Injury to ovary or other pelvic viscera like ureter.

Other risks of IVF include  Ectopic pregnancy.

Increased risk of miscarriage is associated with IVF and  this seems to be due to factors like use of gonadotrophins, PCOS, maternal age and increased risk of miscarriage in women with sub-fertility.

Multiple pregnancy  with increased perinatal mortality and morbidity and increased maternal morbidity is another adverse obstetric outcome of IVF.   This risk can be minimized by strictly following the guidelines set by  HFEA that encourages a single embryo transfer in women who are at most risk of having twins,for example younger women.

A} Being HIV positive , she might be in severe psychological stress so I will take her history in supportive & sympathetic attitude. I will take her history about her diagnosis of HIV test since how long she is diagnosed , other symptoms like loss of weight ,diarrhoea, recurrent fever suggestive of AIDS. I will explore her knowledge about HIV & its long term implications. I will ask her about her menstrual history in detail to know her regularity of period,& associated cyclical pain which may suggest endometriosis. I will ask her past obstetric history to know whether primary or secondary infertility. If she has any children in past from this or other partner & their HIV status should be asked and noted. Her sexual history should be explored as this group of women might have multiple partners & other sexually transmitted infections. I will take her history of any drug abuse  in the form smoking, alcohol, cocaine .History of any intravenous drug use & needle sharing will be asked. Her history of contraception like using condom to reduce the transmission of infection to her partner should be taken as this might be the cause of sub fertility.I will also ask her partner’s HIV status. Her drug history like HAART & vaccination for rubella, Hepatitis. I will ask if she is on prophylaxis or treatment for pneumocystitis carinni pneumonia as this will help for planning of pregnancy. Her partner’s concern towards her HIV status & its implications on future pregnancy should be explored . As it might be causing him psychological stress & a cause of subfertility. I will also ask couple’s wishes for rearing of child if HIV positive as in this case donor gamets can be used.

B} As there is no cause , it is unexplained infertility. I will tell her that without any treatment she may conceive spontaneously in future. As she is HIV positive they might be worried for the HIV status of future child born. So IVF & ET is a good option to reduce vertical transmission of infection as well as a treatment option for infertility. IVF- ET with donor gamets obviates the risk of vertical transmission but couples wishes should be taken into account. If partner HIV status negative IVF-ET may reduce the risk of vertical transmission if Partner’s spermatozoa used . Donor egg can be used for IVF as an alternative. If parner also HIV positive & couple does not want for donor gamets IVF –ET using their own gamets reduces risk of HIV transmission because of sperm washing. There may be a role of preimplantation genetic diagnosis but it is labour intensive & availability of expertise & fascilities is an issue.

Overall IVF procedure requires advanced laboratory, expertise &the treatment is  costly. Success rate of live birth is 20 to 30 percent per cycle. It requires  motivation  &  associated with stress.

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Ideally the couple should bee seen togather and detailed history should be taken out to find out the possible cause of the infertility. i will ask  female partner about her menstural cycle, her  lmp , regularity of cycle. associated dysmenorrhea and vaginal discharge sugestive of pelvic infection , PID. History of wt gain with oligo or amenorrhea , acne oily skin would suggest PCOD. I will ask for galactorrhea as hyperprolactenemia also a cause for infertility and correction of abnormally raised levels would help to improve her fertility.Past obstetrical history taken regarding details of previous pregnancies if any, theit outcomes, previous contraceptive methods used. Detailed medical and surgical  history  regarding Diabetes mellitus ,Hypertension , thyroid disorders, prev abdominal or pelvic surgery taken. I will make sure her smear history is upto date. Details regarding previous investigations( hormonal asssay, tubal assessment ,husband semen analysis) and treatment obtained  like ovulation induction . As she is HIV positive to asssess her general health condition i will ask about whether she is taking HAARt, her recent CD 4 count, any opportunistic infection she is having. whether she is on pnemococcal vaccine as optimization of her heath before conception is necessary to improve pregnancy outcomes and decreases perinatal morbidity and pregnancy associated complications.Hiv physician is involved in her management. i will check her rubella status and offer vacination against HEpatitis B if not previously done  and influenza vaccine in accordance with month of year.  I will ask her about hepatitis c status as coinfection would associated with morbidity. her psycological status checked and her worries and stress regarding infertility and HIv explored in a sensitive way and help from psycologist and contact group offered.  i will offer her with folic acid  5 mg daily till 3 months post conception.

The male partner is inquired about previous children , age of last child born, any history of Dm, HTN ,tuberculosis and inguinoscrotal surgries in past. Drug history is taken as Use of antihypertensive and chemo or radition exposure, use of recreational drugs heavy smoking and alcohol use also affect the sperm and reduces the fertility.  His working environment is explored as  exposure to excessive heat , irradtion , chemicals is not good for fertility.  Detailed sexual history of couple taken to rule out psychosexual problems. His HIv status is determined and if he is HIV negative can advise to limit  sexual activity to fertile days of female menstural cycle. 

B.

Taking into account age of female partner IVF seems to be suitable option for her. Ivf is invasive, expensive and offered at specialized centers . It is not a risk freeprocedure . There is increased risk of ovarian hyperstimulation with gonadotrophins used for ovarian stimulation which may require cycle cancellation. there is increased risk of  ectopic pregnancy, multiple gestations . There is risk to bowel during ovum retrival and if performed under GA risk related to anesthesia are also there. The success rate is only 25% to 30 % per cycle but results seems good in case of unexplained infertility.  If her husband is also HIv positive washed sperms can be used if he has high viral load  to minimize the viral transmission to offsping. Though other option available is IUI with or without controlled ovarian stimulation, less invasive and costly to IVf and it also donot require much expertise  but success rate is  around 20% per cycle. The couple is given detailed information regarding both options and their wishes taken into consideration.