Your partner is likewise fit and well and works as a panel beater. He is a non-smoker and drinks a glass of wine with meals. He does, however, like to smoke marijuana at least once a week. He has not had any previous testicular problems and has not fathered a child.
You are getting anxious and depressed because all your family are expecting you to get pregnant as easily as your two sisters and all your school friends are on at least their second baby by now.
The results would suggest that there is a male factor and so the candidate should explain the various technologies available for you. You feel your partner may get very distressed at the thought that it is probably his problem and not yours.
44
INFERTILITY – CASE NOTES
Mark sheet
Appropriate supplementary history
●
May ask about LMP
●
May ask if partner has had any testicular problems, tumours, infections, operations
●
Asks about smoking, alcohol and any recreational drugs of patient and partner
●
May ask about type of underwear and bathing habits of partner
●
Any previous children
●
May check about coital frequency
●
May ask about Candida and if she has had treatment or is still symptomatic (wrong name)
0
1
2
3
4
5
Discusses investigations and relevance
●
Ovulating normal midluteal progesterone
●
Fallopian tubes patent on the HSG
●
Infection status negative for Chlamydia but positive for Candida (wrong name)
●
Semen results shows main problem is with a low sperm count
●
Further count may be useful but diagnosis is unlikely to be different
●
Notices wrongly labelled result
0
1
2
3
4
5
Discusses appropriate treatment options
●
Never say that the patient can never get pregnant, but may have difficulties
●
Advises to stop marijuana, usual advice about underwear, baths and multi-vitamins
●
Advises that IUI may not be very successful
●
Donor insemination may not be the first line of treatment
●
Suggests reproductive technologies IVF/ICSI
●
NICE guidelines suggest IVF should be available on the NHS
●
Asks patient how far does she want to proceed and adoption may be an option 0
1
2
3
4
5
6
Global score
0
1
2
3
4
Total
/20
45
REVIEW STATIONS
Discussion
What does this question test?
This question has a preparatory station in order to allow the candidate to read the case notes. However, it could be placed at the station to go through with the patient present which would simulate what can happen in reality. The question is looking at whether the candidate can interpret the clinical findings and results. This is the kind of scenario in which one may find oneself in a clinic, with very basic information and copies of letters. It is unlikely that there will be a role-play couple. You may have to counsel either the woman or her partner in a similar situation. It could be the man who you are seeing to discuss his sperm count and this may lead to a very confrontational consultation. The actors will have been primed to ask specific questions in order to lead you along the mark sheet of the examiners.
There are three aspects to what is required and it is important to think of relevant questions related to the low sperm count. With all infertility questions, there will usually be an obvious diagnosis. It is always important to find out how far along the road of assisted treatments a couple is prepared to go.
The examiner will be in place to award marks and nothing else.
What are the pitfalls?
The major pitfall is in answering the question, being critical of the notes and allow-ing yourself time to deal with all three tasks. This is clearly a case of infertility due to a male factor. It is important that the candidate has a clear idea of the normal values of the common tests that are undertaken in the gynaecological outpatient clinic.
In most cases, the normal ranges will be given, but even so the candidate should know the normal range of any test requested. This is particularly true in obstetrics when the normal range may change due to the pregnancy. As in real life, it is important to check that the results belong to the patient in front of you. There may be results that have been deliberately labelled incorrectly and these need to be identified. This is especially true if you are breaking bad news.
Advice
There are three parts to this question. In the preparatory station it is worth making notes of specific parts of the history that have not been addressed or documented to date. These would revolve around any possible reasons for a low sperm count, e.g. drugs, history of previous children, and other social issues. The second part of the question is to interpret the results to the patient and that can only be done if normal values are known. The third part of the question is to discuss the low sperm count and the specific options that may be useful for this case. You would need to have a clear idea about the options and how to get access to them.
46
INFERTILITY – CASE NOTES
What variations are possible for this question?
Alternatives to this question would be endocrinology cases where a number of results are given to the candidate and those results have to be interpreted by the gynaecologist. As the examination may occur over 2–3 days, comparable stations will need to be found for each day, e.g. different causes for infertility, secondary amenorrhoea, etc.
47
Review station 9
Audit
Candidate’s instructions
A copy of an algorithm that is used in the early pregnancy assessment unit is supplied. This protocol was instituted in an attempt to reduce the number of unnecessary ultrasound scans performed.
Discuss with the examiner how you would design an audit to ascertain how well this protocol is being adhered to, and what steps you would take if the audit revealed that overall compliance is poor. You are not being asked to comment or criticize the protocol as such.
YOU WILL BE AWARDED MARKS FOR:
●
Discussing the factors you would take into consideration
●
Designing an audit to address the question
●
Discussing how you would use the results
48
AUDIT
REFERRAL TO EPAU
6 wks amenorrhoea
Positive preg’y test
pv bleeding
Viable preg’y
INCOMPLETE
MISSED
Check blood
Check blood
Discuss
group
group
c mother
ERPC +/–
Conservative
Give anti-D prn
Heavy bleeding
Cervagem
approach
See EPAU
VE
7–10 days
Book via GP
Bleeding
Remove POC’s
settles
May need
re-scan
Bleeding
Treat
continues
conservatively
ERPC