Infertikity

Question 1

Infertility

Answer 1

Failure to achieve pregnancy after 12 months of regular unprotected s

Question 2

Infertility causes male

Answer 2

• 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)

Question 3

what is cryptorchidism?

Answer 3

Testes fail to descend,most stay in inguinal canal

Question 4

Infertility causes female

Answer 4

• 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

Question 5

Endometriosis

Answer 5

Presence of functioning uterine tissue outside uterus
Onset from menarche to menopause
More menstrual pain,menstrual irregularities,infertility,deep dyspareunia
Responds to oestrogen

Question 6

Fibroids

Answer 6

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

Question 7

signalling path of normal hypothalamic-pituitary-gonadal axis?

Answer 7

kisspeptin neurons in hypothalamus → GnRH neurons → gonadotrophs in anterior pituitary → LH and FSH into systemic circulation → testosterone or estrogen

Question 8

what is kallmann syndrome?

Answer 8

GnRH neurons fail to migrate with olfactory fibres from primitive nose to hypothalamus
Symptoms involve anosmia,failure of puberty,infertility

Question 9

effect of hyperprolactinaemia on fertility?

Answer 9

prolactin binds to prolactin receptors on kisspeptin neurons → kisspeptin release inhibited → secondary hypogonadism

Question 10

T difference between oligomenorrhea and amenorrhea?

Answer 10

oligo = more than 35d no menses, a = 3-6m no menses

Question 11

Hyperprolactinaemia treatment

Answer 11

dopamine agonist since dopamine inhibits prolactin, surgery

Question 12

symptoms of klinefelter’s syndrome XXY?

Answer 12

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

Question 13

key history and examination elements in male infertility?

Answer 13

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)

Question 14

Lifestyle treatment for male infertility

Answer 14

optimise BMI, smoking cessation, alcohol reduction

dopamine agonist for prolactin, gonadotropin treatment, testosterone, surgery

Question 15

what is premature ovarian insufficiency?

Answer 15

same symptoms as menopause, run out of ova early but conception can happen in approx 20%

Question 16

How to diagnose POI

Answer 16

high FSH > 25 iU/L (x2 at least 4 weeks apart)

Question 17

Causes of POI

Answer 17

autoimmune

genetic e.g. turner’s syndrome 45X

cancer therapy

Question 18

most common cause of infertility in women?

Answer 18

PCOS

exclude other reproductive disorders

2 out of 3 of Rotterdam PCOS Diagnostic Criteria:

oligo-/anovulation, clinical +/- biochemical hyperandrogenism, polycystic ovaries detected by ultrasound

Question 19

PCOS symptoms and treatment

Answer 19

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

Question 20

symptoms of Turner’s syndrome 45X?

Answer 20

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

Question 21

key elements of history and examination in female infertility?

Answer 21

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

Question 22

Key investigations for infertility

Answer 22

blood tests (FSH, LH, prolactin, oestradiol, androgens, karyotyping)

pregnancy test

transvaginal ultrasound, MRI pituitary

Question 23

Specific treatment for male infertility

Answer 23

Dopamine agonist for hyperprolactinaemia
Gonadotrophin treatment for fertility to increase testosterone
Testosterone
Surgery (micro testicular sperm extraction)

Question 24

Hypogondotrophic hypogonadism

Answer 24

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

Question 25

Hypogonadotrophic hypogogonadism (pituitary)

Answer 25

Hypopituitarism
Tumour,infiltration,apoplexy,surgery,radiation
Low LH,FSH,E2

Question 26

Hypergonadotrophic hypogonadism

Answer 26

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