Infertility

Introduction

Infertility is a significant health concern affecting approximately 16% of Canadian couples. This comprehensive guide is designed to help Canadian medical students prepare for the Medical Council of Canada Qualifying Examination Part I (MCCQE1) by covering key aspects of infertility diagnosis and management in the Canadian healthcare context.

Epidemiology in the Canadian Context

• Prevalence: Approximately 16% of Canadian couples experience infertility
• Age-related trends: Increasing prevalence due to delayed childbearing in Canada
• Regional variations: Higher rates in urban areas compared to rural regions

Etiology of Infertility

Diagnostic Approach for MCCQE1

Key Investigations for MCCQE1

Management Strategies in Canadian Healthcare

1. Lifestyle Modifications

   • Smoking cessation programs (covered by most provincial health plans)
   • Weight management (referral to dietitians covered by some provinces)
   • Stress reduction techniques

2. Ovulation Induction

   • Clomiphene citrate (first-line in Canada)
   • Letrozole (off-label use, but common in Canada)
   • Gonadotropins (covered by some provincial drug plans)

3. Surgical Interventions

   • Laparoscopic surgery for endometriosis or tubal factors
   • Varicocelectomy for male factor infertility

4. Assisted Reproductive Technologies (ART)

   • Intrauterine insemination (IUI)
   • In vitro fertilization (IVF)
   • Intracytoplasmic sperm injection (ICSI)

Canadian Guidelines for Infertility Management

The Society of Obstetricians and Gynaecologists of Canada (SOGC) provides key guidelines for infertility management:

1. Initial workup should begin after 12 months of unsuccessful attempts (or 6 months if female partner is >35 years)
2. Both partners should be assessed simultaneously
3. Ovarian reserve testing is recommended for all women >35 years
4. Semen analysis is a crucial first step in male evaluation
5. Unexplained infertility should be managed with a stepped approach, starting with less invasive treatments

MCCQE1 High-Yield Topics

• 🔑 Definition and prevalence of infertility in Canada
• 🔑 Risk factors specific to the Canadian population
• 🔑 Diagnostic criteria and initial workup
• 🔑 Interpretation of semen analysis results
• 🔑 Indications for specialist referral in the Canadian healthcare system
• 🔑 Provincial variations in ART coverage and access

CanMEDS Roles in Infertility Management

1. Medical Expert: Demonstrate knowledge of infertility causes, diagnosis, and treatment options
2. Communicator: Effectively discuss sensitive infertility issues with patients
3. Collaborator: Work with multidisciplinary teams including reproductive endocrinologists, urologists, and mental health professionals
4. Leader: Understand resource allocation for infertility treatments in the Canadian healthcare system
5. Health Advocate: Promote public health measures to prevent infertility (e.g., STI prevention, timely childbearing education)
6. Scholar: Stay updated on the latest Canadian infertility research and guidelines
7. Professional: Maintain ethical standards in infertility counseling and treatment

Key Points to Remember for MCCQE1

• Infertility affects 16% of Canadian couples
• Initial workup starts after 12 months of trying (6 months if female >35)
• Both partners should be evaluated simultaneously
• Semen analysis is crucial for male factor assessment
• Ovarian reserve testing is recommended for women >35
• Treatment options range from lifestyle modifications to ART
• ART coverage varies by province in Canada
• SOGC guidelines provide the standard of care for infertility management in Canada

Sample Question

A 32-year-old woman and her 34-year-old husband present to their family physician after trying to conceive for 14 months without success. The woman has regular menstrual cycles and no significant medical history. The man has no known medical issues. Which one of the following is the most appropriate next step in management?

• A. Reassure the couple and advise them to continue trying for 6 more months
• B. Start the woman on clomiphene citrate
• C. Refer the couple to a fertility specialist
• D. Perform a hysterosalpingogram on the woman
• E. Recommend in vitro fertilization

Explanation

The correct answer is:

• C. Refer the couple to a fertility specialist

Explanation: According to Canadian guidelines, infertility is defined as the inability to conceive after 12 months of regular, unprotected intercourse. This couple has been trying for 14 months, which meets the criteria for infertility. The most appropriate next step is to refer them to a fertility specialist for a comprehensive evaluation and management plan. Options A and B are incorrect as they delay proper assessment. Options D and E are premature without a complete infertility workup.

References

1. Canadian Fertility and Andrology Society. (2021). Clinical Practice Guidelines. Retrieved from https://cfas.ca/clinical-practice-guidelines.html (opens in a new tab)

2. Bushnik, T., Cook, J. L., Yuzpe, A. A., Tough, S., & Collins, J. (2012). Estimating the prevalence of infertility in Canada. Human Reproduction, 27(3), 738-746.

3. Society of Obstetricians and Gynaecologists of Canada. (2019). Infertility Evaluation and Treatment. JOGC, 41(12), 1735-1749.

4. Government of Canada. (2022). Fertility. Retrieved from https://www.canada.ca/en/public-health/services/fertility/fertility.html (opens in a new tab)

5. Reproductive Care Program of Nova Scotia. (2019). Infertility Management in Primary Care. Retrieved from http://rcp.nshealth.ca/clinical-practice-guidelines/infertility-management-primary-care (opens in a new tab)