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Endocrine > Assessment of Infertility > Flashcards

Assessment of Infertility Flashcards

1
Q

How common is infertility?

A

Affects 1:6 couples (15%) = about half of these couples will conceive either spontaneously or with relatively simple advice/treatment

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2
Q

How much of the population require more complex treatment for infertility?

A

8% remain subfertile and require more in-depth treatment

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3
Q

What are some factors linked with the rise on infertility?

A

Older women, rise in chlamydia, increase in obesity, increasing male factor infertility, increasing awareness of treatment, change in expectations

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4
Q

What are the cumulative conception rates for spontaneous pregnancy?

A

75% at 6 months, 90% at 12 months, 95% at two years

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5
Q

What is infertility defined as?

A

Failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sex (in absence of known reason) in a couple who have never had a child

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6
Q

What are the types of infertility?

A 
Primary = couple have never conceived
Secondary = couple conceived, although pregnancy may not have been successful (e.g miscarriage)
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7
Q

Why is infertility classed as a disease?

A

It causes considerable psychological distress

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8
Q

What are some factors that increase the likelihood of successful spontaneous pregnancy?

A

Women aged <30, previous pregnancy, <3 years trying to conceive, intercourse occurring around ovulation, woman/s BMI 18.5-30, both partners non-smokers, caffeine intake <2 cups of coffee a day, no use of recreational drugs

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9
Q

What are physiological causes of anovulatory infertility?

A

Before puberty, pregnancy, lactation, menopause

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10
Q

What are some gynaecological conditions that cause anovulatory infertility?

A 
Hypothalamic = anorexia/bulimia, excessive exercise
Pituitary = hyperprolactinaemia, tumours, Sheehan's
Ovarian = PCOS, premature ovarian failure
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11
Q

What are some general causes of anovulatory infertility?

A

Chronic renal failure, testosterone-secreting tumours, congenital adrenal hyperplasia, thyroid, drugs (Depo-Provera, explanon, OCP)

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12
Q

How common is anorexia nervosa?

A

Affects 1% of population = more common in women, unknown aetiology

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13
Q

What are some features of anorexia nervosa?

A 
Low BMI (<18.5), loss of hair, increased lanugo, low pulse and BP, anaemia
Endocrine features = low FSH, LH and oestradiol
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14
Q

How common is polycystic ovary syndrome (PCOS)?

A

Most common endocrine disorder in women (20-33%) = usually inherited, exacerbated by weight gain

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15
Q

What are some features of polycystic ovary syndrome?

A

Obesity, hirsutism or acne, cycle abnormalities, infertility

Endocrine features = high free androgens, high LH, impaired glucose tolerance

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16
Q

How is polycystic ovary syndrome diagnosed?

A

Score of 2 out of three of the following = chronic anovulation, polycystic ovaries, hyperandrogenism

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17
Q

What are some causes of premature ovarian failure?

A

Idiopathic, chemo/radiotherapy, oophorectomy

Genetic = missing X chromosome in Turner’s syndrome, fragile X

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18
Q

What are the features of premature ovarian failure?

A

Hot flushes, night sweats, atrophic vaginitis

Endocrine features = high FSH, high LH, low oestradiol

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19
Q

What are some infective causes of tubal disease?

A

Chlamydia, gonorrhoea, anaerobes, syphilis, TB
Spread from appendicitis/intra-abdominal abscess
Following IUCD insertion, hysteroscopy or HSG

20
Q

What are some non-infective causes of tubular disease?

A

Endometriosis, surgical (sterilisation, ectopic pregnancy), fibroids, polyps, congenital, salpingitis isthmica nodosa

21
Q

What are some symptoms of a hydrosalpinx due to pelvic inflammatory disease?

A

Abdominal/pelvic pain, vaginal discharge, dyspareunia, cervical excitation, dysmenorrhoea, infertility, ectopic pregnancy

22
Q

How common is endometriosis?

A

Affects about 20% = 10% of menstruating women, 30% of women with infertility

23
Q

What is endometriosis?

A

Presence of endometrial glands outside uterine cavity

24
Q

What causes endometriosis?

A

Most likely due to retrograde menstruation

May be genetic, or due to altered immune function or abnormal cellular adhesion

25
Q

What are the clinical features of endometriosis?

A

Dysmenorrhoea (classically before menstruation), dyspareunia, painful defaecation, menorrhagia, chronic pelvic pain, fixed and retroverted uterus, “chocolate” cysts on ovary, infertility, asymptomatic in some

26
Q

What are some pre-testicular causes of male infertility?

A 
Endocrine = hypogonadotropic hypogonadism, hypothyroidism, hyperprolactinaemia, diabetes
Coital = erectile dysfunction, ejaculatory failure
27
Q

What are some testicular causes of male infertility?

A

Genetic = Klinefelter syndrome, Y chromosome deletion, immotile cilia syndrome
Congenital = cryptorchidism, infective, antispermatogenic agents
Torsion, varicocele, immunological

28
Q

What are some post-testicular (obstructive) causes of male infertility?

A 
Epididymal = congenital, infective
Vasal = CF, vasectomy, ejaculatory duct obstruction, accessory gland infection
29
Q

What drugs can cause male infertility?

A

Alcohol, tobacco, marijuana, testosterone supplements, SSRI antidepressants, cocaine

30
Q

How do non-obstructive causes of male infertility present?

A

Low testicular volume, reduced secondary sexual characteristics, vas deferens present, high LH and FSH, low testosterone

31
Q

How do obstructive causes of male infertility present?

A

Normal LH, FSH and testosterone, normal testicular volume, normal secondary sexual characteristics, vas deferens may be absent

32
Q

How are couples suffering from infertility seen in clinic?

A

Seen as a couple = take infertility history, gynaecology, andrology, sexual history, social history, PMH, PSH and POH

33
Q

How are females examined for infertility?

A

BMI, general examination (assessing body hair distribution, galactorrhoea), pelvic examination

34
Q

How are males examined for infertility?

A

BMI, general examination, genital examination

35
Q

What investigations are done in females?

A

Endocervical swab for chlamydia, cervical smear if due, blood for rubella immunity

36
Q

How is the midluteal progesterone level investigated in a woman?

A

Day 21 of 28 day cycle or 7 days prior to expected period in prolonged cycles, progesterone >30nmol/L suggests ovulation

37
Q

What are the tests for tubal patency in females, and when are they indicated?

A 
Hysterosalpiniogram = if no known risk factors for tubal/pelvic pathology, laparoscopy contraindicated
Laparoscopy = possible tubal/pelvic disease, known previous pathology, history suggestive of pathology, previous abnormal HSG
38
Q

When is hysteroscopy performed to investigate infertility in females?

A

In cases where there is known/suspected endometrial pathology

39
Q

When is a pelvic US done to investigate infertility in women?

A

When there is an abnormality on the pelvic examination, or when indicated by other investigations

40
Q

What endocrine profile is done to investigate anovulatory cycles and infrequent periods?

A

Urine HCG, prolactin, TSH, testosterone and SHBG, LH, FSH, oestradiol

41
Q

What endocrine profiles are done for hirsute females and those with amenorrhoea?

A 
Hirsute = testosterone and SHBG
Amenorrhoea = same profile as for anovulatory cycles, chromosome analysis
42
Q

How should semen analysis be carried out?

A

Two samples taken over six weeks apart

43
Q

What are the normal parameters for semen?

A

Volume >1.5ml, pH between 7.2-7.8, concentration >15x10^6/ml, motility >50%, morphology >4% with normal morphology, WBC <1x10^6/ml

44
Q

What endocrine profile should be done for a male with abnormal semen analysis?

A

LH, FSH, testosterone, prolactin, thyroid function

45
Q

What investigations should be done in a man with severely abnormal semen analysis or who is azoospermic?

A

Endocrine profile as for abnormal semen profile, chromosome analysis and Y chromosome microdeletions, screen for CF, testicular biopsy

46
Q

When should a scrotal US be done?

A

If the genital examination of the male was abnormal

Endocrine (42 decks)

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