Reproductive endocrinology, infertility and assisted reproduction
Introduction
This domain tests the endocrine control of the cycle, the investigation of infertility, ovulation induction and assisted reproduction, including the Czech legal framework for reimbursement.
Semen analysis (WHO 2021, 6th edition)
- Volume ≥1.4 mL, concentration ≥16 million/mL, total count ≥39 million, progressive motility ≥30%, total motility ≥42%, normal morphology ≥4%, vitality ≥54%.
- Two analyses about three months apart before defining male factor; abnormal results go to andrology or urology review.
Female investigation
- Cycle day 2–4 FSH, LH, oestradiol and AMH for ovarian reserve; TSH and prolactin.
- Tubal patency by hysterosalpingography or laparoscopy; ultrasound for antral follicle count and pelvic pathology.
- Document ovulation (mid-luteal progesterone) before labelling infertility unexplained.
Ovulation induction
- WHO group II anovulation (PCOS by Rotterdam criteria - two of oligo-ovulation or anovulation, hyperandrogenism, polycystic ovarian morphology): letrozole is first line, with clomiphene or low-dose gonadotrophins as alternatives and metformin where insulin resistance is present.
- Monitor follicular growth by ultrasound; with three or more follicles ≥14 mm cancel or convert to IVF to avoid multiple pregnancy and OHSS.
Assisted reproduction
- IVF indications: tubal damage, severe male factor, unexplained infertility after failed simpler treatment, endometriosis, age-related decline.
- Antagonist protocol with GnRH agonist trigger reduces OHSS risk; freeze-all and cabergoline in high-risk cycles. OHSS presents with distension, haemoconcentration and oliguria.
- Czech Act 373/2011 on specific health services governs assisted reproduction: four cycles are reimbursed and only for women before their 40th birthday; professional guidelines recommend single embryo transfer in young women with good prognosis.
Worked example
A 32-year-old with PCOS, BMI 34 and 14 months of infertility has a normal semen analysis and patent tubes. First line is lifestyle change with 5–10% weight loss plus letrozole 2.5 mg on days 2–6, with a follicular scan on day 12. Clomiphene is not preferred because of higher multiple pregnancy rates and anti-oestrogenic effects on the endometrium; metformin is added if insulin resistance is documented.
Traps
- Ordering FSH on a random cycle day.
- Ignoring male factor before proposing intrauterine insemination.
- Using gonadotrophins without ultrasound monitoring.
- Overlooking the age limit and cycle cap in Czech reimbursement rules.