RACGP KFP 2017.2.5 – Failure to Conceive

by | Dec 29, 2017

Answer Keys to RACGP KFP 2017.2, Case 5 – Failure to Conceive

Bill and Alana are 26 year old couple who have been trying to conceive for 7 months, with no success. They seek your help with helping them conceive. Alana has a history of irregular periods, long standing acne, hirsuitism, depression and sleep apnoea. Bill has no significant medical history.

What are the key features of history to ask the female in this couple? (List 6)

  1. Previous history of sexually transmitted infections
  2. previous pregnancies and outcomes
  3. Past genitourinary surgery
  4. Timing and frequency of intercourse
  5. Previous/current contraception use
  6. Painful periods (endometriosis)
  7. Substance abuse
  8. Alcohol intake
  9. Tobacco use

No marks are given for information provided in the stem.

Murtaghs “The sub fertile couple” has a list that is probably the basis of the answer. 

 

What are the most important initial investigations to perform in the female? (list 8)

  1. Sexually Transmitted Infections urinary PCR
  2. Midluteal LH (general and for PCOS)
  3. Midluteal FSH (general and for PCOS)
  4. Midluteal progesterone   (general and for PCOS)
  5. Oestradiol
  6. Pelvic Ultrasound (general and for PCOS)
  7. Serum testosterone – (PCOS)
  8. Fasting BSL (PCOS/DM)
  9. Rubella Immune status (preconception screening)
  10. varicella serology (preconception screening)

In the real exam you would probably have a list to choose from choose.

The point of the demonstration of the technique you want to display is that you want to show you can focus the investigations on the vignette. If in doubt pick the investigations that enable you to demonstrate this rather than the generic screening you would really do. There are countless examples of this preference expressed in the Public Exam Report.

However – in this case – they seemed to want less of a focus on the PCOS in investigations, and to also think broadly to include all the initial investigations for female infertility. So there is some contradiction internally in the advice provided.

Further reading – https://www.aafp.org/afp/2015/0301/p308.html

Semen analysis returns with the following results:

  • Volume > 1.5ml

  • Sperm concentration > 1 million sperm / ml (normal > 15

  • Normal morphology (shape) > 4%

  • Motility > 32% with forward progression

How would you explain the results of this to your patient?

1. Results show a severely low sperm count with normal sperm shape and motility – severe oligospermia

  • This is an obvious severe oligospermia. I don’t know if this is what was assessed in the examination but its worth having a basic understanding of the details of semen analysis, which Ive tried to capture in the references below.

 

RACGP Feedback

This case focused on a young couple presenting with failure to conceive. Candidates were required to consider what history, additional to that provided in the scenario, would be relevant in exploring the possible causes of sub-fertility for the female partner, as well as the initial appropriate investigations for her. Finally, candidates were given the semen analysis for the male partner and were required to describe the result.

The most common errors in this case centred on not reading the question and providing answers relating to a generic pre-conception consultation rather than a sub-fertility consultation. Another common error was to focus solely on the patient’s symptomatology of polycystic ovarian syndrome, rather than considering additional diagnoses underlying a failure to conceive.

The investigation question specialised initial investigations, with the most common error being to select secondary investigations, or investigations that were not relevant given the history provided, such as selecting serum prolactin when the history was not suggestive of a prolactinoma, in preference to other more common causes of sub-fertility.

It is important for candidates to consider all of the information provided in the clinical scenario, as it is pertinent to the subsequent questions.

 

 

References

  1. http://www.isdbweb.org/documents/file/170_management.pdf
  2. https://www.racgp.org.au/afp/2012/october/infertility/
  3. https://jeanhailes.org.au/health-professionals/webinar-library/infertility-causes-management
  4. https://www.racgp.org.au/afp/2012/october/
  5. https://www.howtotreat.com.au/case-report/why-cant-rita-get-pregnant
  6. https://www.aafp.org/afp/2007/0315/p849.pdf
  7. https://www.racgp.org.au/afp/2017/september/male-infertility/
  8. https://www.nps.org.au/australian-prescriber/articles/fertility-testing
  9. https://www.andrologyaustralia.org/wp-content/uploads/Factsheet_SemenAnalysis.pdf
  10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3739681/
  11. https://www.drmalpani.com/knowledge-center/resources/books/chapter4b – good