Endo - Infertility Flashcards by Pavan Khatkar

Define infertility

Failure to achieve clinical pregnancy after 12+ months of regular unprotected sex

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Define regular sex

Every 2-3 days

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What are the 2 types of infertility

Primary and secondary

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What is primary infertility

Never had a live birth

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What is secondary infertility

Had a live birth more than 12 months previously

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Epidemiology of infertility

Affects 1/7 but after a year, half of these will have conceived.
55% seek help - positive association with socio-economic status

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Who is most at fault for infertility

Equal:

30 male, 30 female, 30 male and female, 10 unknown

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What is the impact of infertility

Stress on cuple, lower birth rate in population leads to lower income tax therefore negative societal impact

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What are the male causes of infertility

Pre, intra and post testicular

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What are the pre-testicular causes

Congenital and acquired endocrinopathies e.g. Kinlefleters, HPG, PRL, T, Y chromosome depletion

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what are the testicular causes

Congenital 
Cryptorchidism 
Infection e.g. STD
Immunological e.g. Antisperm ABs
Vascular (varicoele)
Trauma 
Toxins (radiotherapy, chemotherapy, Drugs, smoking)

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What are the post testicular causes of infertility in males

Congenital e.g. CF –> no vas deferens
Erectile dysfunction
Obstructive azoospermia
Iatrogenic e.g. vasectomy

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What is cryptorchidism

Failure of the testis to descend through the inguinal canal into the scrotum

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What are the female causes of infertility from most common to least common

Ovarian 
Tubal 
Uterine
Unexplained 
Cervical 
Pelvic

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What are the pelvic causes of infertility

Endometriosis

Adhesions

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What are the ovarian causes of infertility

Anovulation

Corpus lute insufficiency

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What are the fallopian causes of infertility (tubulopathy)

Infection
Endometriosis
Trauma

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What are the uterine causes of infertility

Chronic endometriosis (TB)
Adhesions (synechiae)
Fibroid
Congenital malformation

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What are the cervical causes of infertility

Chronic cervicitis

Immunological (anti sperm Abs)

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What is endometriosis

Presence of functional endometrial tissue outside the uterus - responds to oestrogen

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What are the symptoms of endometriosis

Deep dyspareunia
Menstrual pain
Menstrual irregularity Infertility

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What are the treatment for endometriosis

Laparoscopic ablation
Hysterectomy
Bilateral salphingo-oophorectomy
Hormones e.g. OCP, progesterone

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What are fibroids

Benign tumours of the endometrium

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What are the symptoms of fibroid

Can be asymptomatic 
Deep dyspareunia 
Menstrual pain
Menstrual irregularity 
Infertility

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What is the treatment for fibroids

Hormones: OCP, progesterone, GnRH antagonist | Hysterectomy

Describe the rhythm of GnRH, LH, FSH vs sex steroids

GnRH therefore LH and FSH have a pulsatile rhythm whereas the sex steroids have a diurnal rhythm

How does negative feedback work in men HPG axis

T is covered to oestrogen for negative feedback

What are the hypothalamic causes of male infertility

Kallman sydrome Acquired hypogonadotrophic hypogonadism Hyperprolactinemia

What are the pituitary causes of male infertility

Hypopituitarism

What are the pre-testicular post pituitary causes of male infertility

Klinefelters | Acquired primary hypogonadism (cryptorchidism, trauma, DXT, chemo)

What happens in Kallmann syndrome

Congenital hypogonadotrophic hypogonadism where during the first 10 weeks of embryonic development, there is failure of GnRH neurones to migrate from the olfactory placode with the olfactory fibres to the hypothalamus

What are the features of Kallmann

``` Anosmia (can be normosmic) Cryptorchidism Failure of puberty Lack of testicle development Micropenis Primary amenorrhoea Infertility ```

What happens in hyperprolactinemia

Prolactin binds to kisspeptin neurones inhibiting the release of kisspeptin and thus GnRH

What is oligomenorrhoea

Irregular or infrequent periods longer than 35 day cycles or 4-9 per year

What is amenorrhoea

No periods for 3-6 months or up to 3 a year

What are the signs of Klinefelter's

``` Tall stature Low IQ Narrow shoulders Wide hips Low bone density Small penis Breast development Lack of pubic or facial hair - female pubic hair pattern ```

What is a normal sperm concentration

15 million sperm/ ml

What is a normal sperm motility

40%

What is azoospermia

No sperm

What is oligospermia

Reduced sperm

What are the main investigations we do when males present with infertility

Semen analysis Blood tests Microbiolgoy Imaging

What is the general treatment for male infertility

Optimise BMI Smoking cessation Alcohol reduction

What is the specific treatment for male infertility

Dopamine agonist Gonadotropin treatment Testosterone Surgery

Before investigating female infertility, what should we make sure of first

Make sure not pregnant or breast feeding

What is primary amenorrhoea

Hasn't had first period at 16

What is secondary amenorrhoea

Periods start but then stop for at least 3-6 months

What is POI

Primary ovarian insufficiency: early menopause

What are the POI symptoms

Same as per menopause

What are POI conception rates

20% - the odd egg may be released

What is POI diagnosis

High FSH > 25 iU/L - 2 readings at least 4 weeks apart

What are the causes of POI

Autoimmune Genetic Cancer therapy e.g. DXT/ Chemo

What is a gonadal ovarian cause of female infertility

PCOS

PCOS epidemiology

Affects 5-15% of women at reductive age - most common endocrine disorder in women and most common cause of infertility

What do we use to diagnose PCOS

Rotterdam PCOS diagnostic criteria

What is the worst metabolic risk combination for PCOS

Oligo/anovulation and Hyperandrogenism

What do we use to treat PCOS

``` Metformin OCP Clomiphene, letrozole, IVF Diet and lifestyle Creams, waxing, laser Anti-adnrogens e.g. spironolactone Progesterone courses ```

What is Turner's syndrome

45 X0 - congenital hypergonadotrophic hypogonadism

What are the signs of Turner's

``` Short Low hairline Webbed neck Shielded chest Coarctation of the aorta Wide nipples Brown nevi Amemnorrhoea Elbow deformity Poor breast development Underdeveloped repro. tract ```

What are the blood tests we perform for female infertility

``` LH, FSH, PRL Oestradiol, androgens. Follicular phase 17-OHP, mid luteal progesterone SHBG Albumin/ Fe Pituitary/ TSH/fT4 Karyotype ```

What other investigations do we do for female infertility

Pregnancy test Microbiology Imaging