7. Infertility (lecture) Flashcards
what is the definition of infertility?
failure of conception in a couple having regular, unprotected coitus for one year
what is primary and secondary infertility?
primary: no previous pregnancy
secondary: previous pregnancy, successful or not
about how many couples will have difficulty conceiving in the UK?
1 in 7 couples
what aspects of history do you ask for in an infertile female?
age duration of infertility menstrual cycle - length and predictability of cycle, age of menarche tubal / pelvic surgery PID menorrhagia (abnormally heavy periods) pelvic pain sexual history - any infections?
what aspects of history do you ask for in an infertile male?
general health alcohol / smoking previous surgery to the testes drug history previous infections sexual dysfunction
what do you examine in infertility?
BMI
signs of secondary sexual characteristics (e.g. chromosomal abnormalities)
galactorrhoea (milky secretion from the breasts)
pelvic examination - feel for structural abnormalities
additionally, what do you check for in males?
testicular size and check for descent (from lumbar spine)
do NOT perform male examination without relevant history
what are the most common aetiology of infertility?
male factors - 30% Ovulatory disorders - 25% tubal damage - 20% uterine / peritoneal disease <10% others (no identified male / female cause) - 25%
what is the most common male factor causing infertility?
idiopathic oligospermia (deficiency of sperm cells in the semen)
aside from idiopathic oligospermia, what are the other causes of infertility in males?
Varicocele
Abnormal sperm production (e.g. testicular disease)
Hypothalamic / pituitary dysfunction (not enough testosterone, so can’t produce sperm)
Ductal obstruction - post infective epididymitis, post vasectomy
Failure to deliver sperm to the vagina (hypospadias, impotence)
what is hypospadias? (leading to failure to deliver sperm to vagina)
a congenital condition in males in which the opening of the urethra is on the underside of the penis (instead of at glans penis)
what is impotence in men (leading to failure to deliver sperm to vagina)?
inability in a man to achieve an erection or orgasm
what is varicocele in men (leading to infertility)?
when veins become enlarged inside scrotum
what are the different classifications of ovulatory disorders?
- Hypothalamic pituitary failure (GnRH to AP)
- Hypothalamic-pituitary-ovarian dysfunction (GnRH, or AP affecting ovaries theca cells)
- Ovarian failure (has stimulation but theca cells not producing oestrogen)
what is polycystic ovary syndrome?
syndrome consisting of polycystic ovaries and systemic features resulting from elevated androgens
what are the causes of polycystic ovary syndrome?
unknown pathophysiology, but appears to have genetic component
what does polycystic ovary syndrome cause?
Increased androgen secretion (testosterone)
Raised LH/FSH ratio (disrupt ovulation, not enough FSH to cause follicles to mature in time for the LH surges)
Insulin resistance
Multiple small ovarian cyst
Anovulation
what is anovulation in PCOS?
ovaries do not release an oocyte during a menstrual cycle, so no ovulation
what are examples of anovulation in PCOS?
amenorrhoea (absence of menstrual periods)
oligomenorrhoea (infrequent menstrual periods)
what are clinical features of ovulatory disorders e.g. PCOS?
Hirsutism Acne Obesity Male-pattern baldness Oligomenorrhoea (infrequent menstrual periods) Psychological symptoms
what is Hirsutism in PCOS?
excessive body hair in men and women on parts of the body where hair is normally absent or minimal, such as on the chin or chest in particular
what are psychological symptoms that can be present in PCOS?
mood swings
depression
anxiety
what is the Rotterdam Diagnostic criteria for PCOS?
2/3 of the following:
Polycystic ovaries (12 or more follicles on ultrasound)
Oligo-ovulation / anovulation
Clinical and or biochemical signs of hyperandrogenism
Exclusion of other causes of androgen excess
what is Oligo-ovulation? (PCOS)
infrequent, irregular ovulation
what is anovulation? (PCOS)
the ovaries do not release an oocyte during a menstrual cycle, ovulation doesn’t happen
what is hyperandrogenism? (PCOS)
excess androgens (testosterone)
what are causes of tubal damage causing infertility?
past pelvic infection e.g. Chlamydia previous pregnancies pelvic surgery endometriosis Mullerian developmental anomaly
what is endometriosis? (cause of tubal damage causing infertility)
Presence of endometrial tissue in sites other than the uterine cavity (commonly pelvic cavity)
affects 10-15% women
(tissue that behaves like the lining of the womb (the endometrium) is found outside the womb)
what does Mullerian duct form?
primordial anlage of the female reproductive tract:
fallopian tubes, uterus, the uterine cervix
what are causes of uterine / peritoneal disease leading to infertility?
endometriosis Asherman's syndrome uterine fibroids cervical stenosis cervical hostility
what causes cervical hostility?
infection or female sperm antibodies
what is Asherman’s syndrome? (cause of uterine / peritoneal disease leading to infertility)
formation of adhesions (scar tissue) inside the uterus and/or the cervix
what are uterine fibroids? (cause of uterine / peritoneal disease leading to infertility)
benign smooth muscle tumours of the uterus
(Most women have no symptoms while others may have painful or heavy periods. If large enough, they may push on the bladder causing a frequent need to urinate)
what are clinical features of endometriosis?
Dysmenorrhoea (low anterior pelvic pain which occurs in association with periods)
Dyspareunia (difficult or painful sexual intercourse)
chronic pelvic pain
infertility
what are causes of other factors leading to infertility?
unexplained infertility
poorly controlled diabetes
coital problems (sex position)
multifactorial in 5-10% of cases
