Endo - Infertility Flashcards
Define infertility
Failure to achieve clinical pregnancy after 12+ months of regular unprotected sex
Define regular sex
Every 2-3 days
What are the 2 types of infertility
Primary and secondary
What is primary infertility
Never had a live birth
What is secondary infertility
Had a live birth more than 12 months previously
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
Who is most at fault for infertility
Equal:
30 male, 30 female, 30 male and female, 10 unknown
What is the impact of infertility
Stress on cuple, lower birth rate in population leads to lower income tax therefore negative societal impact
What are the male causes of infertility
Pre, intra and post testicular
What are the pre-testicular causes
Congenital and acquired endocrinopathies e.g. Kinlefleters, HPG, PRL, T, Y chromosome depletion
what are the testicular causes
Congenital Cryptorchidism Infection e.g. STD Immunological e.g. Antisperm ABs Vascular (varicoele) Trauma Toxins (radiotherapy, chemotherapy, Drugs, smoking)
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
What is cryptorchidism
Failure of the testis to descend through the inguinal canal into the scrotum
What are the female causes of infertility from most common to least common
Ovarian Tubal Uterine Unexplained Cervical Pelvic
What are the pelvic causes of infertility
Endometriosis
Adhesions
What are the ovarian causes of infertility
Anovulation
Corpus lute insufficiency
What are the fallopian causes of infertility (tubulopathy)
Infection
Endometriosis
Trauma
What are the uterine causes of infertility
Chronic endometriosis (TB)
Adhesions (synechiae)
Fibroid
Congenital malformation
What are the cervical causes of infertility
Chronic cervicitis
Immunological (anti sperm Abs)
What is endometriosis
Presence of functional endometrial tissue outside the uterus - responds to oestrogen
What are the symptoms of endometriosis
Deep dyspareunia
Menstrual pain
Menstrual irregularity Infertility
What are the treatment for endometriosis
Laparoscopic ablation
Hysterectomy
Bilateral salphingo-oophorectomy
Hormones e.g. OCP, progesterone
What are fibroids
Benign tumours of the endometrium
What are the symptoms of fibroid
Can be asymptomatic Deep dyspareunia Menstrual pain Menstrual irregularity Infertility
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
