Infertikity Flashcards
Infertility
Failure to achieve pregnancy after 12 months of regular unprotected s
Infertility causes male
- pre-testicularcongenital and acquired endocrinopathiese.g. kleinfelter’s 47XXY, HPG axis/testosterone/prolactin issues
- testicularcryptorchidism, STDs, anti-sperm antibodies, varicocele, trauma, toxins
- post-testicularcongenital absence of vas deferens, obstructive azoospermia, erectile dysfunction +/- retrograde ejaculation, iatrogenic (vasectomy)
what is cryptorchidism?
Testes fail to descend,most stay in inguinal canal
Infertility causes female
- ovarian causesanovulation (endo), corpus luteum insufficiency
- tubal causesendometriosis, infection, trauma
- uterine causescongenital malformations, infection/inflammation/scarring, fibroids
- cervical causesineffective sperm penetration bc inflammation, infection, immunological (anti sperm Ab)
- pelvic causesendometriosis, adhesions
Endometriosis
Presence of functioning uterine tissue outside uterus
Onset from menarche to menopause
More menstrual pain,menstrual irregularities,infertility,deep dyspareunia
Responds to oestrogen
Fibroids
Benign myometrium tumours
Onset post menopausal women common as your older
Usually asymptomatic can be more menstrual pain irregularities infertility or dyspareunia
Respond to oestrogen
signalling path of normal hypothalamic-pituitary-gonadal axis?
kisspeptin neurons in hypothalamus → GnRH neurons → gonadotrophs in anterior pituitary → LH and FSH into systemic circulation → testosterone or estrogen
what is kallmann syndrome?
GnRH neurons fail to migrate with olfactory fibres from primitive nose to hypothalamus
Symptoms involve anosmia,failure of puberty,infertility
effect of hyperprolactinaemia on fertility?
prolactin binds to prolactin receptors on kisspeptin neurons → kisspeptin release inhibited → secondary hypogonadism
T difference between oligomenorrhea and amenorrhea?
oligo = more than 35d no menses, a = 3-6m no menses
Hyperprolactinaemia treatment
dopamine agonist since dopamine inhibits prolactin, surgery
symptoms of klinefelter’s syndrome XXY?
tall, mildly impaired IQ, wide hips, breast development, less facial and chest hair, small genitals, infertility, low bone density
- duration, previous children, pubertal milestones, associated symptoms, medicationsBMI, sexual characteristics, testicular volume, anosmia
key history and examination elements in male infertility?
duration, previous children, pubertal milestones, associated symptoms, medications
BMI, sexual characteristics, testicular volume, anosmia
Invertsuage sperm analysis (azoospermia/oligospermia = no/few sperm), blood tests (LH, FSH, prolactin, morning fasting testosterone, karyotyping), imaging (scrotal ultrasound, pituitary MRI)
Lifestyle treatment for male infertility
optimise BMI, smoking cessation, alcohol reduction
dopamine agonist for prolactin, gonadotropin treatment, testosterone, surgery
what is premature ovarian insufficiency?
same symptoms as menopause, run out of ova early but conception can happen in approx 20%
How to diagnose POI
high FSH > 25 iU/L (x2 at least 4 weeks apart)
Causes of POI
autoimmune
genetic e.g. turner’s syndrome 45X
cancer therapy
most common cause of infertility in women?
PCOS
exclude other reproductive disorders
2 out of 3 of Rotterdam PCOS Diagnostic Criteria:
oligo-/anovulation, clinical +/- biochemical hyperandrogenism, polycystic ovaries detected by ultrasound
PCOS symptoms and treatment
irregular menses/amenorrhoea and infertility
greater insulin resistance
hirsutism
heightened risk of endometrial cancer
Treat with oral contraceptives,ovulation induction,metformin,diet and lifestyle,anti androgens eg spironolactone,progesterone
symptoms of Turner’s syndrome 45X?
short stature, shield chest with wide spaced nipples, poor breast development, webbed neck, coarctation (partial narrowing) of aorta, underdeveloped reproductive tract, amenorrhoea, brown nevi (spots/moles)
High LH/FSH and low testosterone and oestrogen
key elements of history and examination in female infertility?
duration, previous children, pubertal milestones, menstrual history, medications
BMI, sexual characteristics, hyperandrogenism signs, anosmia
Do blood test to check for LH,FSH,PRL,mid luteal prog,karyotyping,pregnancy test. Imaging such as ultrasound,hysterosalpinogram,MRI pituitary
Key investigations for infertility
blood tests (FSH, LH, prolactin, oestradiol, androgens, karyotyping)
pregnancy test
transvaginal ultrasound, MRI pituitary
Specific treatment for male infertility
Dopamine agonist for hyperprolactinaemia
Gonadotrophin treatment for fertility to increase testosterone
Testosterone
Surgery (micro testicular sperm extraction)
Hypogondotrophic hypogonadism
Low GnRH,low LH FSH E2
Congenital hypogonadotrophic hypogonadism eg anosmic (kallman) or normosmic
Acquired hypogondotrophic hypogonadism due to low bmi,XS exercise and stress
Hyperprolactinaemia
In women hypothalamic amenorrhea
Hypogonadotrophic hypogogonadism (pituitary)
Hypopituitarism
Tumour,infiltration,apoplexy,surgery,radiation
Low LH,FSH,E2
Hypergonadotrophic hypogonadism
Females high LH FSH low e2
Acquired primary hypogonadism POI due to sruergy trauma chemo or radiation
Congenital primary hypogonadism eg turners or POI
PCOS LH FSH high and e2 low or normal,
Males
Congenital primary hypogonadism eg klinefelters
Acquired primary hypogonadism eg cryptorchidsm trauma chemo radiation
High LH FSH low testosterone
Primary vs secondary infertility
Primary
Have not had a love birth previously
Secondary
Have had a love birth >12 months previously
Regular intercourse is every 2-3 days
How many ppl does it affect
1 in 7 couples but half of these conceive in next 12 months
