NATIONAL QUALIFICATIONS CURRICULUM SUPPORT
Human Biology
Unit 2: Physiology and Health
Case Study on Infertility
Teacher’s Guide
[HIGHER]
The Scottish Qualifications Authority regularly reviews
the arrangements for National Qualifications. Users of
all NQ support materials, whether published by
Learning and Teaching Scotland or others, are
reminded that it is their responsibility to check that the
support materials correspond to the requirements of the
current arrangements.
Acknowledgement
Learning and Teaching Scotland gratefully acknowledges this contribution to the National
Qualifications support programme for Human Biology.
With grateful thanks to the Aberdeen Fertility Centre for so much help and advice in producing
this case study.
© Learning and Teaching Scotland 2011
This resource may be reproduced in whole or in part for educational purposes by educational
establishments in Scotland provided that no profit accrues at any stage.
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Contents
Introduction
4
Case study on infertility
6
Consulting their GP
6
Fertility clinic – first visit
9
Fertility clinic – second visit
15
Fertility clinic – third visit
16
Assisted reproduction unit – first visit
17
Assisted reproduction unit – second visit
18
Assisted reproduction unit – third visit
21
Assisted reproduction unit – fourth visit
22
Assisted reproduction unit – fifth visit
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CASE STUDY ON INFERTILITY
Unit 2: Physiology and Health
1.
Reproduction (b) The biology of controlling fertility
Introduction
Overview
The following is a research based study. It outlines the journey a couple,
Kirsty and Andrew, take from infertility to a baby. Students have to research
various topics – some minor, some major. Suggested websites should supply
all information. In particular, the Human Fertilisation and Embryology
Authority and Aberdeen Fertility Centre websites are extremely informative.
A small glossary is supplied to help complete the medical report forms and
reduce the time taken if pupils decide to extend their learning by researching
certain conditions/treatments that are not required for this course.
Approach
The work can be approached in a variety of ways :
 an individual piece of research, eg as homework
 group work either in school/college or as homework
 a class project.
Students are asked to produce a report of the medical case, which should
include the forms provided plus the andrology reports.
They are also asked to write Kirsty’s blog of her journey.
Report
Depending on the class involved, the report could be produced:




4
as
as
as
as
role play (depends on the people/class involved)
a written report, as per paper medical records
electronic medical records (depends on accessibility to PCs)
a PowerPoint presentation of findings
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 as a podcast (Kirsty is a news journalist, so it could be by her,
interviewing various people).
Requirements
 Each student/group should have a copy of the case study, suggested
websites, glossary and forms.
 If these are being given out in paper form, please copy the forms onto th e
appropriate coloured paper.
 Students should have access to a medical dictionary plus the internet.
Information
General guidelines for expected responses to the areas of study are given in
italic on the Teacher’s guide.
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Case study on infertility
Below is a history of a couple who suffered from fertility problems.
You are the health practitioner who is in charge of their case.
Follow their history and produce a report of their medical case and any
research they undertook.
Kirsty and Andrew MacDonald
Kirsty is 27 and works as a news journalist on the local radio station. Andrew
is 35 and is a self-employed plumber, with his own business. They have been
married for four years and have been trying to start a family for just over two
years.
Andrew has a 14-year-old son from a previous relationship.
Being a journalist, Kirsty always keeps a diary. As you proceed through this,
turn her diary into a blog that may help other couples undergoing the same or
similar problems.
Visit to GP
Kirsty was attending her medical centre for a scheduled cervical smear test.
She was chatting to the nurse and told her that she was trying to get pregnant,
but so far had not been successful. The nurse gave her some general advice
about health and lifestyle, and advised her to consult the GP if she was still
not pregnant after another six months.
 What general advice would the nurse have given to help the couple achieve
a healthy pregnancy?
Ideal body weight (BMI between 20 and 25)
Healthy diet – plenty of fresh fruit and vegetables
Regular, moderate, exercise
Restrict alcohol intake
Stop smoking
Be careful of prescribed, over-the-counter and recreational drug use.
Kirsty should take folic acid supplements to help health of any foetus.
Kirsty took on board what the nurse had said. Andrew was more reticent.
Six months later they arranged an appointment with their GP, Dr Glenesk, as
Kirsty was still not pregnant. The GP spoke to them both and arranged
various tests for Kirsty and Andrew.
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 What general questions would the GP have asked?
Do they have regular coitus?
Does Kirsty have any abnormal bleeding or discharge?
Does Andrew have any problems with erection or ejaculation ?
Dr Glenesk also spent time ensuring that the couple understood how to
calculate when Kirsty was most fertile.
 Outline the advice Kirsty was given in order to calculate her most fertile
time.
The first day of the period is counted as day 1. Ovulation usually occurs
between day 13 and day 15.
Kirsty should record her body temperature daily. At ovulation, t he
temperature rises by 0.2–0.5°C. The period of fertility lasts three to four
days, despite the temperature remaining high for about 13 days – the
luteal phase.
The GP asked Kirsty when the first day of her last period was. From this, she
arranged for a blood sample to be taken on day 21 of her cycle.
 What hormone will the blood sample be used to test for?
Test for progesterone levels – if high, ovulation has occurred.
Kirsty is under 30, so a urine sample was taken.(If she was over 30 this would
not be considered a priority)
 What common sexually transmitted infection (STI) was being tested for?
Chlamydia
 What would Andrew be tested for?
Semen analysis and and STIs
The GP examined both Kirsty and Andrew, including an internal examination
for Kirsty and a genital examination for Andrew.
Andrew works long hours and lunch is usually from the baker or chip shop.
He often goes out for a drink after work with the other plumbers. None of
them smoke. They enjoy friendly banter, but he is finding the teasing a bout
Kirsty not being pregnant stressful, despite him laughing it off. His business
is successful, but he also finds it quite stressful. He used to play in a local
league football team, but hurt his back about a year ago. He never went to the
doctor. His back still bothers him but he finds that regular ibuprofen helps.
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His genital examination showed no problems.
The sperm analysis is still to be done.
Kirsty eats healthily and goes swimming every Monday and to a Zumba class
on a Thursday. She walks to and from work – about a 15-minute journey. She
has been eating very healthily and taking folic acid to help the foetus if she
becomes pregnant. She is a non-smoker. She has a glass of wine after work on
a Friday with colleagues, and she and Andrew share a bottle of wine with
their evening meal on both a Saturday and a Sunday. She is not taking any
medication.
Her work is also very stressful, with many demands.
Kirsty’s tests and examination at the GP were all clear.
 Is there any relevance in the above information, which they shared with
their GP?
Andrew – poor diet. Can affect sperm production
Lack of exercise. This with poor diet can increase BMI which can affect
reproductive function.
Drinks regularly – alcohol can reduce semen quality
Stress – affects general health, sleep patterns etc.
Regular ibuprofen, which can cause fertility problems in some men if taken
regularly.
Non-smoker. This is good!
Kirsty – keeps fit and eats healthily. That’s good.
Stress from work and from trying to get pregnant. Affects general health.
Non-smoker.
The GP decides to refer them to the fertility clinic of their local hospital.
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Fertility clinic – first visit
They receive an appointment at the clinic. Andrew was asked to supply a
semen sample in advance so that the results would be available for this
appointment. They are told that the sample must be produced after three to
seven days of sexual abstinence.
 Why is this?
To ensure the best quality of sperm for analysis .
When they arrive for their appointment, they spen d time with a senior doctor,
who takes a full medical history and is able to discuss any worries they have.
 Complete the appropriate forms (1–4) for Kirsty and Andrew, based on the
information given at the clinic and also to the GP (you can complete some
parts using made up/local addresses/names, etc)
Complete forms 1–4
Kirsty
She has regular periods, of between four and six days. Her menstrual cycle is
between 28 and 30 days.
She has never had any abnormal bleeding or vaginal discharge.
She has no history of pelvic inflammatory disease or STD.
Her appendix ruptured and was removed in an emergency operation when she
was 17.
She has never taken recreational drugs.
She stopped taking the combined oral contraceptive pill 31 months ago.
She has never been pregnant.
Andrew
He has no history of urinary infection or STD.
He has never had mumps.
He has never taken recreational drugs.
Both
They have frequent coitus – on average three times a week.
They are aware of the fertile period and try to increase coitus at this time.
They do not have any sexual problems.
Andrew has no problems with erection or ejaculation.
Test results
Kirsty’s blood tests, taken by the GP, show that she is ovulating normally.
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Andrology – Andrew’s semen analysis
The doctor explains that semen analysis is the easiest way of assessing male
fertility. Even if a man has already fathered a child, the semen is still
analysed as male fertility can change. This may be due to age, illness or a
change in lifestyle.
He explains to them that the results provide information about:
volume – how much semen is produced
concentration– how many sperm are present per millilitre of semen
motility – how many sperm are moving and how quickly they are moving
morphology – how many sperm are of normal shape and size.
He then takes out Andrew’s results.
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Semen analysis report
WHO 2010 guidelines
Forename
Surname
Patient
Andrew
MacDonald
Partner
Kirsty
MacDonald
Referring doctor
Dr Glenesk,
Practice
Columba Medical Practice
Sample date
Time produced
10:40
Time analysed
11:17
Date of birth
Days abstinence
4
Analysis time delay
00:37
Acceptable
Parameter
Patient result
Lower reference value
Volume
3.7 ml
1.5 ml
Sperm concentration
14.5 million/ml
15 million/ml
Total number of sperm
in ejaculate
39.65 million
39 million
Progressive motility
28%
32%
Morphology
7%
4% normal
Please note that the lower reference values comply with the World Health
Organization 2010 guidelines for semen analysis.
Comments
If progressive motility, sperm concentration or sample volume are lower than
the reference values, or if morphology is below 3% normal forms, referral to
the fertility clinic should be considered.
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 What does the doctor have to tell Andrew and Kirsty?
Volume of semen is good.
Sperm concentration and numbers are quite low but higher than the lower
threshold.
Motility is also low.
Morphology is acceptable.
 How does this affect Andrew’s fertility?
Andrew’s fertility is low. This will cause difficulty trying to achieve
pregnancy with Kirsty.
Andrew and Kirsty have a lot to discuss with the doctor. Consider what his
responses would be to the following points.
1.
Andrew points out that he already has a son .
Fertility can change throughout a man’s life. As he already has a son,
his current condition is referred to as secondary infertility.
2.
Andrew is worried that this makes him ‘less of a man’.
Not at all. Many men have low sperm counts, for a variety of reasons
3.
What might be the reason/cause of these results?
Lifestyle – drinking and unhealthy diet. Stress. Regular use of
ibuprofen.
4.
Can they do anything, themselves, to help improve the situation?
Improve diet. Reduce alcohol. Stop regular use of ibuprofen. More
exercise for Andrew. Reassess lifestyle to try to reduce stress.
5.
What options do they have?
Based on Andrew’s results only, they could consider sperm collection
followed by intrauterine insemination (IUI).
6.
What happens next?
Kirsty has to undertake some tests.
The doctor explains that they should both undergo a physical examination t o
check for any other underlying problems.
Kirsty and Andrew are given some time to go to the café and discuss these
results between themselves. Kirsty is told to drink a lot and not go to the
toilet!
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They then return to the fertility centre and meet Alison, a nurse. Alison will
be their link nurse from now on, so they are always communicating with the
same person.
 Why is this arrangement put in place?
Infertility treatment is a stressful process and having the same person to
work with and speak to helps to build up a supportive relationship for
Kirsty and Andrew.
Alison explains what examinations will take place, then they go back to see
the doctor, who carries out the examinations.
Alison accompanies Kirsty for her examination.
 Why does she do this?
A female patient cannot undergo an internal examination by a male doctor
without a female nurse being present (to protect both of them from any
allegations).
Kirsty
Height 166 cm. Weight 64 kg.
Blood pressure 118/69.
General examination was normal.
Hair distribution and breast development are normal.
No breast lumps.
Abdominal examination showed a large scar on the lower right side of
Kirsty’s abdomen. She explained this was from the appendicectomy she had.
It had been a difficult operation as the append ix presented in an unusual
position.
Pelvic examination – all appeared normal.
Kirsty’s GP had already arranged a chlamydia test, which was clear.
Kirsty’s last smear was only six months ago and clear.
No further swabs were taken.
Andrew
Height 180 cm. Weight 87 kg.
Blood pressure 142/90.
General examination was normal.
Testes, epididymides, scrotum and penis – all normal.
Alison, meanwhile, does an ultrasound scan on Kirsty, which requires a full
bladder.
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After Kirsty visits the toilet, Alison explains that another test they need to
undertake is a hysterosalpinogram (HSG), which is an X -ray of the uterus and
ovaries, using a special dye. She arranges an appointment for this, giving
them a leaflet explaining the procedure and stressing the following wa rning:
Important
There is a risk to a pregnancy conceived during a cycle when X -rays are
carried out, so please make sure you DO NOT get pregnant that month.
Please either avoid intercourse or use barrier contraception from the first
day of the cycle in which you are having the X-ray until the start of your
next period.
Kirsty is distressed at the idea of using contraception when she is trying to
conceive, but Alison stresses that the risk to an embryo is too great, as the Xray can cause malformations.
Kirsty is told to phone the fertility clinic secretary at the beginning of her
next cycle to arrange a date and is told to also book a review appointment
with the doctors for around three weeks after the X-ray.
Alison then sits down with them both to answer any other questions. She
discusses lifestyle changes with Kirsty and Andrew, and explains that the
clinic can arrange appointments with dieticians and counsellors if they wish.
 Start completing form 5 – summary sheet. This will require updating as
you continue, going on to sheet 6 – continuation sheet.
Hysterosalpinogram
When Kirsty attends for her HSG, dye (which shows up on X -rays) is passed
through her cervix to outline the uterus and the oviducts. This require s a
vaginal examination like a smear test. When the dye was being introduced she
felt some discomfort similar to period pain.
X-ray pictures were taken while the dye was being introduced , giving a
continuous picture of the dye filling the tubes and spilling out.
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Fertility clinic – second visit
Kirsty and Andrew meet Alison again, who chats to them about lifestyle
changes they have made and how they are feeling, in general.
Andrew has improved his diet and lost 5 kg.
He went to an osteopath for help with his back pain, which has improved. He
is no longer taking ibuprofen.
He has cut back his drinking and does not go to the pub with his colleagues
so often. When he does, he usually opts for shandy or a soft drink. He finds it
has given him a bit more time to himself, so he has started go ing out for an
evening walk and has occasionally joined Kirsty when she goes swimming.
Kirsty has been encouraging and supporting Andrew. They no longer drink on
a Sunday, only sharing one bottle of wine on a Saturday.
They then speak to the doctor for the results from Kirsty’s ultrasound scan
and the HSG.
It was explained that Kirsty has adhesions, which are pulling her ovaries out
of place. Adhesions are where two normally separate surfaces are joined by
fibrous connective tissue developing in a damage d region. This means that,
although she is ovulating normally, there is little chance of the ovum entering
the oviduct.
Kirsty and Andrew are, naturally, quite upset at this news. They had been
feeling positive about the lifestyle changes they had made a nd feel this is a
real blow.
The doctor discusses the options open to them.
 What might be the cause of Kirsty’s adhesions?
The emergency appendecectomy when she was 17 .
 What might be done to help with the adhesions Kirsty suffers from?
Surgery could cut the adhesion, but may cause more scar tissue.
 What other options are there?
In vitro fertilisation.
Kirsty would, ideally, like to conceive naturally, so she opts for surgery to
treat the adhesions.
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Operation
Some months later, she has an operation for her adhesions, called
adhesiolysis. Unfortunately it is not a success.
Post operation
To cheer Kirsty up, Andrew arranges a holiday abroad. They have a fortnight
in Thailand. Unfortunately, he contracts malaria, despite taking a
prophylactic drug. He is quite ill, with a high fever, and is treated with
chloroquine.
Fertility clinic – third visit
Kirsty and Andrew speak to the doctor again. He explains that, as the
operation was not successful, Kirsty cannot conceive naturally.
He advises that they consider in vitro fertilisation (IVF).
They have already done some personal research on their problems, so agree to
this readily.
The doctor says he will refer them to the assisted reproduction unit (ARU).
They then have another chat with Alison. She explains that there is currently
a wait of approximately two years for IVF on the NHS. Kirsty is very upset at
this thought, as it is now almost a year since they first sought help from their
GP and three years since they began trying to start a family. However, they
put their names down on the NHS waiting list.
Checkpoint! Check the work done so far, before the main research phase.
Post visit
After their latest consultation at the fertility centre, Kirsty and Andrew have a
long discussion. Andrew’s business is doing very well and they have a good
income, so they decide that they can afford to seek private IVF treatment.
Although they have been very impressed with the support and treatment they
have received at their local fertility centre, they decide t hat, as they are
paying for it, they would like to find out which ARU has the greatest success
rate for pregnancy and will suit them best.
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 Go to the Human Fertilisation and Embryology Authority website at
www.hfea.gov.uk and
http://www.hfea.gov.uk/docs/11897_hfea_fertility_treatment_v10.pdf .
 Find the HFEA booklet ‘Getting started: Your guide to fertility treatment’
and research the different centres with their success rates. Put this in a
short report, with your recommendations for Kirsty and Andrew.
 Try to use graphs/charts to illustrate your findings.
There is no set answer here. The decision will depend on the individual
research and, in particular, on which part of the country this is being
researched from. Although one ARU may be slightly cheaper than another, if
the student is, for example, researching this in Peterhead, the added cost of
attending a centre in Glasgow would make i t more expensive.
The results should include success rate for IVF , the costs involved, location,
etc.
Assisted reproduction unit – first visit
Kirsty and Andrew have followed your advice regarding which centre to use
and the appropriate referral was made by the infertility centre.
They have to complete various consent forms before they start treatment.
They also have to undergo a ‘welfare of the child’ assessment.
 What is this and why must they undergo this assessment?
The Human Fertilisation and Embryology Act states:
‘A woman shall not be provided with any treatment services unless
account has been taken of the welfare of any child who may be born as a
result of the treatment and of any other child who may be affected by the
birth.’
They attend an information evening before their first consultation, where
much information is given, followed by a tour of the unit.
At their consultation, the doctor consults their notes and ensures he is up to
date with their more recent medical history. He is slight ly concerned to hear
that Andrew had contracted malaria and that he was treated with chloroquine.
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 Why is this of concern?
Malaria is a pyrexial illness – it causes a fever. Body temperature is
increased, which can affect sperm production.
Chloroquine can affect sperm production (reduction in number, reduced
motility and an increase in the number of abnormal sperm) .
Routine blood samples are taken to test for hepatitis B, hepatitis C and HIV.
Kirsty and Andrew then complete various consent forms. They are able to ask
any questions they have about the treatment.
The doctor asks Andrew if he would supply another sample for semen
analysis and an appointment is made for him for the following week.
Arrangements are made for Kirsty’s treatment to start, based on her menstrual
cycle.
 Outline the three stages of treatment/checks which Kirsty will undertake at
the centre before her eggs are collected.
1. The treatment cycle of drugs, starting at day 2 or 21 .
2. Ultrasound scans after about 12–17 days to monitor the response to
the drugs and see if the next cycle can commence .
3. Blood samples to monitor responses to the stimulation drugs .
 What are the hormones (drugs) used at each stage and what do they do?
1.
Gonadotrophin releasing hormone (GnRH) is administered to inhibit
Follicle Stimluating Hormone (FSH)/Luteinising Hormone (LH) from
the pituitary gland. This prevents any interference with the
stimulated follicular development.
2.
FSH and human menopausal gonadotrophin (HMG) is given to
stimulate follicular development.
3.
Human chorionic gonadotrophin (HCG) matures the eggs (having
the same action as LH).
4.
Progesterone prepares the endometrium for implantation.
Assisted reproduction unit – second visit
Andrew, meanwhile, has supplied another semen sample, which was analysed .
The doctor discusses the results with them.
His recent illness and its treatment have had a negative effect on his fertility.
His sperm count is now lower than in the original sample as are sperm
motility and morphology.
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As fertilisation will be by IVF, the embryologist should be able to collect
enough sperm from his sample. However, as a precaution, he is advised that it
would be worthwhile to produce an extra couple of samples, which can be
frozen until the day of fertilisation.
Results of the blood tests for both Kirsty and Andrew show them both to be
free of hepatitis B, hepatitis C and HIV.
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Semen analysis report
WHO 2010 guidelines
Forename
Surname
Patient
Andrew
MacDonald
Partner
Kirsty
MacDonald
Referring doctor
Dr Macalister,
Practice
Scotia ARU
Sample date
Time Produced
09.30
Time Analysed
10.25
Date of birth
Days abstinence
4
Analysis time delay
00:55
Acceptable
Parameter
Patient result
Lower reference value
Volume
3.7 ml
1.5ml
Sperm concentration
13 million/ml
15 million/ml
Total number of sperm
in ejaculate
40.2 million
39 million
Progressive motility
25%
32%
Morphology
3%
4% normal
Please note that the lower reference values comply with the World Health
Organization 2010 guidelines for semen analysis.
Comments
If progressive motility, sperm concentration or sample volume are lower than
the reference values, or if morphology is below 3% normal forms, referral to
the fertility clinic should be considered.
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Treatment
Kirsty commences her treatment to stimulate multiple ovulation.
During this time, Andrew goes in to the centre and supplies another semen
sample, which is then frozen.
Assisted reproduction unit – third visit
Kirsty and Andrew undergo various procedures.
 Outline what happens to Kirsty
34–38 hours before her eggs were due to be collected, she had a hormone
injection to help the eggs mature.
Collecting the eggs: Kirsty was sedated, then eggs were collected by
ultrasound guidance. This involves a needle being inserted into the
scanning probe and into each ovary. The eggs are collected through the
needle. She is warned that she may have some cramping and a small
amount of vaginal bleeding afterwards.
She is then given medication (progesterone) to help prepare the uterus
lining for embryo transfer. This is given as pessaries, injection or gel.
 What must Andrew do?
Andrew must supply a fresh semen sample.
 What does the embryologist do?
Kirsty’s eggs are mixed with Andrew’s sperm and cultured in the
laboratory for 16–20 hours. They are then checked to see if any have
fertilised.
Those that have been fertilised (now called embryos) are grown in the
laboratory incubator for another one to two days before being checked
again. The best one or two embryos will be chosen for transfer.
They return a couple of days later for the embryo transfer.
They go in to see the doctor, who tells them that he has bad news for them.
Fertilisation was unsuccessful. They have now discovered that (just to add to
their problems) Kirsty’s eggs and Andrew’s sperm are incompatible and the
egg will not let the sperm enter.
Dr Macalister then explains that they can try intra -cytoplasmic sperm
injection (ICSI).
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 Find out about and outline the ICSI process .
ICSI is when a single sperm is injected directly into an egg in order to
fertilise it. The fertilised egg (embryo) is then transferred to the woman’s
uterus.
After a suitable break to allow Kirsty’s body to recover from the treatment
cycle, arrangements are made for her to begin another treatment cycle.
Assisted reproduction unit – fourth visit
Kirsty and Andrew have undergone the same procedures as before for IVF.
Egg collection from Kirsty takes place. Eight eggs are collected.
Andrew supplies a fresh sample of semen, then the embryologist selects
sperm and injects them into the eggs. The eggs are incubated in a nutrient
medium until the next day, then examined.
The embryologist phones Kirsty and Andrew to tell them that five of the eggs
have fertilised. An appointment is made for two days later for embryo
transfer.
Assisted reproduction unit – fifth visit
After discussion with the embryologist, it is decided to transfer two of the
embryos into Kirsty’s uterus.
 Why did they only transfer two embryos?
Multiple births can cause problems for the mother and the developing
embryos/foetuses.
 What are the options for the other embryos?
Freezing them in case they are required in future.
Kirsty is told to rest for the next few days.
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Two weeks later
Two weeks after embryo transfer, Kirsty must perform a pregnancy test at
home.
She does this and she and Andrew are delighted to find that she is pregnant.
She phones the ARU and informs them of her good news. They congratulate
her and arrange for a scan in three weeks’ time.
Scan
Five weeks after embryo transfer, Kirsty undergoes a scan. They discover that
she is carrying one healthy embryo. Kirsty and Andrew are delighted.
She has a further appointment with medical, embryology and nursing staff.
All goes well, and she continues with a healthy pregnancy and is able to have
a natural birth, giving birth to a healthy baby girl.
The fertility centre and ARU are delighted for them and a photo of baby
MacDonald is taken to add to their ‘wall of success’ – photos of all the babies
who have been born through the ARU.
Kirsty and Andrew remove their names from the NHS waiting list.
With grateful thanks to the Aberdeen Fertility Centre for so much help and
advice in producing this case study.
INFERTILITY (H, HUMAN BIOLOGY)
© Learning and Teaching Scotland 2011
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