1b Infertility Flashcards
What is Infertility?
A disease of the reproductive system defined by the failure to achieve a clinical pregnancy after ≥12 months of regular unprotected sexual intercourse.
What is primary infertility?
not had a live birth previously
What is secondary infertility?
Had a live birth over 12 months ago
What is the most common cause on infertility?
Combined Male and Female Factors
Cost of infertility to the couple:
- No biological child
- Impact on couples wellbeing
- Impact on larger family
- Treatments and Investigations (which often fail = more distress)
What is the cost of infertility to society?
- Less births
- Less tax income
- Investigation costs
- Treatment costs
What are the pre-testicular causes of infertility? - MALE
Endocrinopathies eg Klinefelter 47XXY
Issues with HPG Axis, T, PRL
What is cryptochordism?
Undescended testis - testis start embryologically in the inguinal canal, therefore undescended means they are left there
What toxins can cause infertility?
Chemo, DXT (deep x-ray therapy- radiation), Drugs, Smoking
What are the testicular causes of Infertility
Cryptorchidism
Immunological
Vascular
Trauma / Surgery
Toxins
What are the post testicular causes of infertility?
- Congenital e.g. absence of vascular deferents (CF)
- Obstructive Azoospermia
- Erectile Dysfunction
- Iatrogenic e.g. vasectomy
What are the uterine causes of infertility?
(10%)
Congenital Malformation
Infection/ Inflammation/ Scarring (adhesions)
Fibroids
What are the tubular causes of infertility? - FEMALE
Infection, Trauma, Endometriosis
What are the ovarian causes of infertility?
Anovulation - no ovulation
Corpus Luteum Insufficiency
What is endometriosis?
Presence of functioning endometrial tissue outside the uterus
Why does endometriosis cause increased period pains
Endometriosis responds to oestrogen
Mid cycle oestrogen increases therefore exacerbates menstrual pain
What are the symptoms of endometriosis?
Increased menstrual Pain
Menstrual irregularities
Deep dyspareunia
Infertility
What are fibroids?
BENIGN TUMOURS OF THE MYOMETRIUM
What are the symptoms associated with fibroids?
Usually Asymptomatic
Increased menstrual Pain
Menstrual irregularities
Deep dyspareunia (pain during intercourse)
Infertility
How is Oestrogen made in Males?
Aromatised from testosterone
Describe the HPG Axis?
- kisspeptin binds to kisspeptin receptors
- Stimulates GnRH release
- Binds to gonadotrophs - FSH and LH secretion, which leads to T and O secretion at the gonads
Describe the hormone profile in hyperprolactinaemia?
↓GnRH (Not measurable in the systemic circulation)
↓LH
↓FSH
↓Testosterone
Describe the hormone profile in Kallmann Syndrome?
↓GnRH (Not measurable in the systemic circulation)
↓LH
↓FSH
↓Testosterone
What are some causes of acquired hypogonadotrophic hypogonadism? (female)
Low BMI, Excess Exercise, Stress = No Periods, Anorexia Nervosa
What is meant by anosmic?
No sense of smell
What can cause hypopituitarism?
Apoplexy (haemorrhage/stroke), Tumour, Infiltration, Surgery, Radiation
What is the hormone profile in hypopituitarism?
↓LH
↓FSH
↓Testosterone
What is congenital Primary Hypogonadism (male)?
Klinefelters (47XXY)
What is the hormone profile in Klinefelters?
↑LH
↑FSH
↓Testosterone
What can cause acquired primary hypogonadism (males) ?
Cryptorchidism, Trauma, Chemo, Radiation
What is the cause of Kallmanns Syndrome?
Congenital failure of migration of GnRH neurones with the olfactory fibres - can lead to anosmia
Causes failure of puberty
Infertility
What is the treatment for hyperprolactinaemia?
Dopamine Agonist - Cabergoline
Surgery
What are the symptoms of prolactinaemia?
Oligo or Amenorrhoea, Low Libido, Infertility
What are the symptoms of Klinefelter?
Tall
Mildly Impaired IQ
Reduced Chest Hair
Wide Hips
Low Bone Density
Small Penis / Testes
Breast Development
Female Like Pubic Hair Patterns
What are the blood tests which should be conducted for Male Infertility?
LH, FSH, PRL
Morning Fasting Testosterone - Highest in the morning, and fasting as glucose can impact T
Karyotyping
Semen Analysis
What imaging should be conducted for male infertility investigation?
Scrotal US / Doppler - if Testicular Volume is irregular
Pituitary MRI - if LH, FSH etc is low
What are the key examinations which should be performed for investigating male infertility?
BMI, sexual characteristics, testicular volume, anosmia
What are the lifestyle treatments for male infertility?
Optimise BMI
Smoking Cessation
Alcohol Reduction
How is male infertility treated?
Gondaotrophin treatment
Why is giving males only testosterone not helpful in increasing fertility?
Will treat low libido, and other associated symptoms, however testosterone inhibits sperm production so therefore will not help fertility
Describe the hormone profile seen in Premature Ovarian Insufficiency?
↑LH
↑FSH
↓Oestradiol
What test results are needed to diagnose Premature Ovarian Insufficiency?
High FSH (>25iU/L) - x2 at least 4 weeks apart
What are the causes of premature ovarian Insufficiency?
Autoimmune
Genetics eg Turners
Cancer Therapy
What is the hormone profile in hypothalamic amenorrhoea?
↓GnRH - Not Measureable
↓LH
↓FSH
↓E2
What is the hormone profile seen in PCOS?
↓E2
↑LH:FSH Ratio
Describe the causes of congenital Primary Hypogonadism in females?
turners Syndrome
Premature Ovarian Insufficiency
What are the three Rotterdam PCOS Diagnostic?
- Oligo / Anovulation
- Clinical +/- Biochemical Hyperandrogenism
- Polycystic Ovaries (Polycystic Ovaries morphology are not the same as the syndrome)
What are the clinical symptoms of hyperandrogenism?
Acne
Hirsutism
Alopecia
What are the biochemical symptoms of hyperandrogenism?
raised Androgens - testosterone
What are the treatment options for Irregular Menses?
oral Contraceptive Pill
What are the treatment options for Insulin Resistance?
Metformin, Diet and Lifestyle
What are the treatment options for Hirsutism?
Creams, Waxing and Laser
Anti-Androgens like spironolone = Mineralcorticoid receptor antagonist
What are the implications of PCOS?
Irregular Menses
Infertility
Increased Insulin Resistance
Hirsutism
Increased Endometrial cancer Risk
Describe the hormone profile in turners Syndrome?
↑LH
↑FSH
↓Testosterone
= Hypergonadotrophic hypogonadism
What are the signs of Turner’s Syndrome?
Short Stature
Low Hairline
Shield Chest
Wide Spaced Nipples
Small Finger Nails
Brown Nevi
Webbed Neck
Poor Breast Development
Amenorrhoea
What blood tests should be done when investigating female infertility?
LH
FSH
PRL
Oestradiol, Androgens
Mid-Luteal Progesterone
Karyotyping
