Fertility and Subfertility Flashcards
What is the definition of subfertile?
If conception has not occurred after a year of regular unprotected intercourse.
What is primary subfertility?
The female partner has never conceived
What is secondary subfertility?
Indicating that the female partner has previously conceived, even if the pregnancy ended in miscarriage or termination
What are the four conditions for pregnancy/ where it could go wrong?
- An egg must be produced
- Adequate sperm must be released
- The sperm must reach the egg
- The fertilised egg must implant
What are the main causes of subfertility?
Ovulatory problems - 30% Male problems - 25% Tubal problems - 25% Coital problems - 5% Cervical problems <5% Unexplained - 30% (more than one issue may be present, which is why it doesn't add to 100%)
What are the main ways of detecting ovulation?
Mid-luteal phase serum progesterone (standard test)
US follicular tracking (time-consuming)
LH-based urine predictor kits
PCOS causes anovulation, what is PCO?
It describes transvaginal US appearance of multiple (>12) small (2-8mm) follicles in an enlarged (>10mL) ovary.
What is needed to diagnose PCOS?
At least two of the following three:
[1] PCO on US
[2] Irregular periods (>35 days apart)
[3] Hirsutism: clinical (acne or excess body hair) and/or biochemical (raised serum testosterone)
How does the pathology of PCOS lead to increased androgens?
Disordered LH production and peripheral insulin resistance with compensatory raised insulin levels. This combination leads to increase ovarian androgen production. Raised insulin levels increase adrenal androgen production and reduce hepatic production of steroid hormone binding globulin which leads to increased free androgen levels
What is the effect of increased androgens in PCOS?
Increased intraovarian androgens disrupt folliculogenesis leading to excess small ovarian follicles and irregular or absent ovulation. Raised peripheral androgens cause hirsutism.
What are the modifiable risk factors of PCOS?
Increased body weight leads to increased insulin and consequently androgen levels. Many women have a family history of type 2 diabetes.
What are the clinical features of PCO?
Polycystic ovaries without the syndrome generally cause no symptoms
What are the clinical features of PCOS?
Obesity, acne, hirsutism and oligomenorrhoea or amenorrhoea. Miscarriage is more common in PCOS
What are the investigations needed for PCOS?
Alternative causes for the symptoms need to be excluded.
TVS US
FSH, LH (often raised), testosterone, prolactin, TSH blood tests
Fasting lipids and glucose to screen for complications
Why is FSH measured when investigating PCOS?
It is raised in ovarian failure, low in hypothalamic disease, normal in PCOS.
Why is testosterone measured when investigating PCOS?
To investigate hirsutism: possibility of androgen-secreting tumour or congenital adrenal hyperplasia if very raised
What are the complications of PCOS?
Type 2 DM, GDM
Endometrial cancer is more common in women with many years of amenorrhoea due to unopposed oestrogen action.
How do you treat the symptoms other than infertility?
Advice on weight.
Combined oral contraceptive pill
Metformin will reduce insulin levels and therefore androgens and hirsutism.
What are the hypothalamic causes of anovulation?
Hypothalamic hypogonadism and Kallmann’s syndrome
What is hypothalamic hypogonadism and how does it cause anovulation?
A reduction in hypothalamic GnRH release causes amenorrhea, because reduced stimulation of the pituitary reduces FSH and LH levels, which in turn reduces oestrodiol levels.
In which women is hypothalamic hypogonadism common?
Anorexia nervosa sufferers, women on diets, athletes and those under stress.
What is Kallmann’s syndrome and how can you treat it?
GnRH secreting neurones fail to develop. Exogenous gonadotropins or a GnRH pump will induce ovulation
What is the pituitary cause of anovulation?
Hyperprolactinaemia
What is hyperprolactionaemia and what is it usually caused by?
Excess prolactin secretion, which reduces GnRH release. It is usually caused by a benign tumour or hyperplasia of pituitary cells