Fertility, sub-fertility and infertility Flashcards
Define infertility
Define primary infertility
Define secondary infertility
Infertility: failure to achieve a clinical pregnancy after 12 months or more of regular unprotectedsexual intercourse
Primary infertility: When a couple have never been able to conceive
Secondary infertility: : When people who, have had a first baby without any difficulty, find they cannot get pregnant again, or may have conceived and had a miscarriage or ectopic pregnancy
What are causes of female infertility? [8]
Erratic ovulation
Blocked uterine tubes
Endometriosis
Pituitary or ovarian tumours
Pelvic inflammatory disease
Antisperm antibodies
Age
Polycystic ovary (PCOS)
What are the 4 types of ovulatory causes of infertility? [4]
Type 1: hypothalamic
* hypothalamic amenorrhea
* anorexia nervosa (both men and women)
Type 2: pituitary:
* Hyperprolactinaemia - increase prolactin (mimics that you are breasfeeding: causes decrease in LH & FSH)
Type 3: ovarian:
* Premature ovarian failure
Type 4:
* polycystic ovary syndrome (PCOS)
How many women have PCOS? [1]
33%
Explain pathophysiology of PCOS
Oocytes develop in the ovary, but have become ovarian cysts (follicles that have not ovulated - become fluid filled and cover outer surface)
Occurs because of hyperandrogenism (increased testosterone) in reproductve system
highly genetic
What scoring system is used to ID PCOS? [1]
What score need to diagnose PCOS? [1]
Name 3 things that could get a point for this system? [3]
Rotterdam criteria: need 2/3
* Clinical hyperandrogenism (high testosterone)
* Oligomenorrhoea (less than 6-9 menses per year)
* PCOS on ultrasound
Explain why testosterone is raised in PCOS [3]
PCOS:
Initial response to LH from follicle.
At around 8cm follicle development stops: granulosa cells are lost.
Normally testosterone would be converted to oestrogen, but now doesnt: so secreted out
What would levels of LH, FSH & free testosterone be like in PCOS patients? [3]
FSH: Raised
LH: normal
Free Testosterone: Raised
Treatment options for PCOS?
PCOS is an endocrine condition with systemic effects. Its management must be tailored to each individual’s features and their own wellbeing goals. Aspects of management include:
Menstrual irregularity and endometrial cancer risks
Improving fertility
Reducing hyperandrogenism
Reducing metabolic and cardiovascular complications
Psychological wellbeing
Explain 5 tubal / uterine causes of infertility
Pelvic inflammatory disease:
* Bacterial infection spreading to vagina or cervix causes blockages / inflammation of uterine tubes OR adhesions that stick uterus to uterine tubes
* Commonly chlamdyia or gonorrhoea
Previous tubal surgery
* E.g for ectopic pregnancy
Endometriosis
* Bits of endometrium are outside of uterine cavity (e.g. on fallopian tube or bowell - will grow and develop due to oestrogen and progesterone. But when stop during in menstrual cycle: will bleed. Causes discomfort
Fibriods
* uterine smooth muscle growth and creates nodules (causing discomfort)
* stops uterus wall expanding properly when pregnant
* causes heavy periods & pain on intercourse
cervical mucus defects
* transforms into hostile environment all the time (instead of changing to hostile environment mid-cycle)
When do fibroids classically dissapear and why? [2]
Fibroids occur due to XS oestrogen
During menopause: drop in oestrogen levels and fibroids shrink
What is the main pathophysiology behind repeated miscarriages from?
(lots of reasons)
Main: blood coagulation protein / platelet defects
* Defects in factor XIII and factor XII
* Having anti-cardiolpin antibodies, lupus anticoagulant or antiphospholipid syndrome
others include:
- Anatomical anomalies - cervical incompetence
- Genetic / chromsome abnormalities - trisomy 21 etc
- Endocrine / hormonal abnormalities
MOST ARE TREATABLE
How can you treat blood coagulation protein / platelet defects causing repeated miscarriages? [1]
Aspirin
Name 4 reasons why male infertility may occur
- less than 120 million sperm
- Hormone imbalance (hypogonadism)
- Anti-sperm antibodies
- Varicocele (varicous veins of testes)
- Sperm quality and movement
- Undescended testis
- Obstruction (vasectomy, cystic fibrosis)
- Ejaculatory problems (retrograde and premature)
- Erectile dysfunction
Explain immunological causes of combined infertility
Develop antisperm antibodies (ASA): IgG, IgA and IgM
Causes a breakdown of blood testis barrier (usually blood shouldn’t come in contact with sperm) because its only haploid - is recognised as foreign so is broken down
Explain a genetic cause of combined infertility
During male development SRY downfeeds to SF-1 which causes get rid of uterus when developing in men.
Mutation in gene NR5A1 that codes for SF-1 causes 46XY but with non obstructive male infertility:
Can develop female external external genitalia, uturus and uterine BUT no gonads
OR can have low testosterone and develop azoospermia
1/4 couples investigated for inability have what cause of infertility
Unexplained!
E.g. ovalation is regular, ovarian reserves are OK, uterine tubes re fine etc, so no explanation can explain why not infertilty is occurring
What are 4 reasons why unexplained infertility may occur
Celiac disease
Thyroid imbalance
Folate deficiency
High sperm DNA damage
What factors do you assess for when conducting a normal semen analysis? [5]
Total count
% alive
% normal
% motile
Volume
Morphology
Sperm DNA integrity is not routine (but can be checked for)
What test would you use to check sperm DNA integrity? [1]
Sperm chromatin integrity test
Investigating infertility with a PCOS screen - what would you assess? [5]
- Day 21 progesterone - if greater than 30nmol / L indicates ovulation viable.
- Raised LH
- Normal / Slightly raised FSH
- Raised testosterone
- Abnormal glucose (because DMT2 is big risk factor)
Investigating infertility apart from PCOS - would you you investigate? [5]
Thyroid (TSH / TFT levels)
Vitamin D levels (increased vit D is better)
HbA1C
Viral screen - Rubella, HIV, hepatits
STI screen (undiagnosed chlamydia or gonorrheaa)
What are secondary care investigations would conduct to assess ovulatory function?
Bloods from primary care
Ovarian reserve: Response to gonadotrophin stimulation in IVF
Assess tubal function: Hysterosalpingogram
Assess uterine function
Laparoscopy
Define Intrauterine insemination
Intrauterine insemination (IUI): manually put sperm into the uterus, fertilisation occurs normally.
What assisted reproductive option would you use if IUI was not successful?
In vitro fertilisation (IVF): fertilise eggs outside the body and then inseminated. Requires a working uterus
Explain what intracytoplasmic sperm injection (ICSI) is
Single sperm injected directly into an egg. Requires a working uterus
Which pathology is consequence of long term assisted reproduction techniques? [1]
Ovarian hyperstimulation syndrome: consequence of drugs used to stimulate ovarian function in IVF.
Presents similarly to PCOS as get cysts developing
What is a potential risk for children who are born from women over 35 with IVF? [1]
What is a potential risk for mothers who have children, who are over 35 and use IVF? [1]
Increase in congenital defects
Increase in cancer for the mothers
What is a potential risk for children who are born from women over 35 with IVF? [1]
What is a potential risk for mothers who have children, who are over 35 and use IVF? [1]
Increase in congenital defects
Increase in cancer for the mothers
