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, Toxins, Drugs, Smoking
What are the testicular causes of Infertility
Cryptochordism
Immunological
Vascular
Trauma / Surgery
Toxins
Infection
What are the post testicular causes of infertility?
Congenital - absense of vas deferens
Obstructive Azoospermia
Erectile Dysfunction
Iatrogenic
What are the uterine causes of infertility?
Congenital Malformation
Infection
Scarring/Inflammation/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
Infertility
How is Oestrogen made in Males?
Aromatised from testosterone
Describe the HPG Axis?
- kiss peptin binds to kiss peptin receptors
- Stimulates GnRH release
- Binds to gonadotrophs - FSH and LH secretion, which leads to T and O secretion
Describe the hormone profile in hyperprolactinaemia?
↓GnRH (Not measurable in the systemic circulation)
↓LH
↓FSH
↓Testosterone
Hormone profile in Kallmann syndrome?
All decreased
Hypogonadotrophic and hypogonadism
How does hyperprolactinaemia cause decreased hormones?
Prolactin binds to kisspeptin neurons in hypothalamus
Inhibits kisspeptin release
Decreases downstream GnRH/LH/FSH/T/Oest
Causes oligo or amenorrhoea or low labido
Treatment for hyperprolactinaemia
Dopamine agonist
What can cause hypopituitarism?
Apoplexy, Tumour, Infiltration, Surgery, Radiation
What is the hormone profile in hypopituitarism?
↓LH
↓FSH
↓Testosterone
What is congenital Primary Hypogonadism in males?
Klinefelters (47XXY)
What is the hormone profile in Klinefelters?
↑LH
↑FSH
↓Testosterone
What cause cause acquired primary hypogonadism?
Cryptochordism, Trauma, Chemo, Radiation
What is the cause of Kallmanns Syndrome?
Failure of migration of GnRH neurones with the olfactory fibres - can lead to anosmia
Causes failure of puberty
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 eetc 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
Dopamine agonist for hyperPRL
Testorone for symptoms
Surgery eg micro testicukar sperm extraction)
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 (8-9 cycles a year)/ Anovulation
- Clinical +/- Biochemical Hyperandrogenism
- Polycystic Ovaries (Polycystic Ovaries morphology are not the same as the syndrome)
What are the treatment options for Irregular Menses?
oral Contraceptive Pill and IVF
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
Coractation of the Aorta
What blood tests should be done when investigating female infertility?
LH
FSH
PRL
Oestradiol, Androgens
Mid-Luteal Progesterone
Karyotyping
What is a cause of uterine infertility which is oestrogen responsive?
fibroids
What is klinefelters also known as?
Primary testicular failure
In Kallmann Syndrome, where are the neurones supposed to migrate to and from?
From the hypothalamus to the olfactory placode
What is premature ovarian insufficiency also known as?
early menopause
what hormone pattern would you see in anorexia nervosa-induced amenorrhoea?
LH Down
FSH Down and Oestradiol Down
What imaging is done in female infertility?
US transvaginal
Hysterosalpingogram
MRI Pituitary
