Infertility Flashcards
What is Infertility?
A disease of the reproductive system defined by the failure to achieve a clinical pregnancy after ≥12 months of regular unprotected sexual intercourse.’
What is primary infertility?
When they have not had a live birth …
What is secondary infertility?
When have had a live birth more than 12 months previously
Is it a male factor or female?
Combination
What psychological distress is caused?
No biological child
- Impact on couples wellbeing
- Impact on larger family
- Investigations
- Treatments (often fail)
How does infertility affect society?
Less births
- Less tax income
- Investigation costs
- Treatment costs
What pre-testicular infertility causes are there?
Congenital & Acquired Endocrinopathies
Klinefelters 47XXY
Y chromosome deletion
HPG, T, PRL
What testicular infertility causes are there? 6
(Congenital)
Cryptorchidism
Infection STDs
Immunological Antisperm Abs
Vascular Varicocoele
Trauma/Surgery
Toxins
Chemo/DXT/Drugs/Smoking
What post testicular causes are there for infertility?
Congenital: - Absence of vas deferens in CF
Obstructive Azoospermia
Erectile Dysfunction Retrograde Ejaculation Mechanical Impairment Psychological
Iatrogenic Vasectomy
What is cryptorchidism?
Men:
Normal path down for testis descent is through inguinal canal sometimes this path remains undescended
What causes are there for female infertility?
- Uterine causes
- Tubal causes
- Pelvic causes
- Ovarian causes
- Cervical causes
- Unexplained
What Uterine causes are there for infertility?
Unfavourable endometrium due:
- Chronic endometritis (TB)
- Fibroid
- Adhesions (Synechiae)
- Congenital malformation
What tubal causes are there for infertility in women?
Make up for 30%
Tublopathy which can be due to:
- Infection
- Endometriosis
- Trauma
What pelvic causes are there for infertility in women?
Make up for 5%
- Endometriosis
- Adhesions
What cervical causes are there for infertility in women?
Make up for 5%
Ineffective sperm penetration due:
- Chronic cervicitis
- Immunological (antisperm Ab)
What ovarian causes are there for infertility in women?
Make up for 40%
- Anovulation (endo)
- Corpus Luteum Insufficiency
What is Endometriosis?
Presence of functioning endometrial tissue outside the uterus
- found in 5% of women
- Responds to oestrogen
What are the symptoms of endometriosis?
↑ Menstrual pain
Menstrual irregularities
Deep dyspareunia
Infertility
What are the treatments for endometriosis?
Hormonal (eg continuous OCP, prog)
Laparascopic ablation
Hysterectomy
Bilateral Salpingo-oophorectomy
What is Fibroids and how does this cause infertility?
Benign tumours of the myometrium
1-20% of pre-menopausal women (increases w age)
-Responds to oestrogen
What are the symptoms of fibroids?
Usually asymptomatic
↑ Menstrual pain
Menstrual irregularities
Deep dyspareunia
Infertility
(similar symptoms as endometriosis)
What are the treatments for fibroids?
Hormonal (eg continuous OCP, prog, continuous GnRH agonists)
Hysterectomy ( if in endometrium )
What are the effects of congenital Hypogonadotrophic Hypogonadism
If Anosmic it is Kallmanns syndome (loss of smell is distinguishable factor)
Or
Normosmic hypogonadotrophic hypogonadism
Low GnRH
Low LH FSH
Low T
Not measurable
What are the effects of Acquired Hypogonadotrophic Hypogonadism
-Low BMI, excessive exercise, Stress
Low LH FSH
Low T
What can cause hypopituitarism in men and what affect does this have?
Tumour Infiltration Apoplexy Surgery Radiation
Low LH FSH
Low T
What is congenital primary hypogonadism and how does this affect serum levels?
Kleinefelters 47XXY
High LH FSH
Low T
How can a man get acquired primary hypogonadism?
- Cryptorchidism
- Trauma
- Chemo
- Radiation
High LH FSH
Low T
what rare diseases can cause male infertility?
Androgen receptor deficiency
What is Kallmann syndrome and how does it affect smell
During embryo development GnRH neurones migrate from olfactory placode to hypothalamus, if there is GnRH migration it will also cause olfactory migration issue.
- Anosmia
- Cryptorchidism
- Failure of puberty : lack of testicle development, micropenis, primary amenhorrhoea (in women), infertility
What do we need dopamine agonist such as Cabergoline for?
Hyperprolactinaemia
- slide 21
What sex chromosome disorders are there?
males:
XXY - klinefelter
XYY syndrome
females:
XXX - triple X syndrome
X0 - Turner syndrome
Fragile X syndrome
What physical manifestations occur in Klinefelters?
Tall Decreased facial hair Breast development Female type pubic hair pattern Small penis + testes Infertility Wide hips Low bone density Reduced chest hair Narrow shoulders Mildly impaired IQ
- symptoms are typically more severe if three or more X chromosomes are present * 48,XXXY, 49,XXXXY
What to ask during a male infertility history?
- including duration,
- previous children,
- pubertal milestones,
- associated symptoms (eg. T deficiency, PRL symptoms, CHH features),
- medical & surgical history, - family history,
- social history, - medications/drugs
What examinations to conduct on male infertility?
- BMI
- sexual characteristics
- testicular volume
- epididymal hardness
- presence of vas deferens
- other endo signs
- anosimia
What is a normal semen analysis:
1.5ml volume
15 mill/ml sperm concentration
40% Total motility
What is azopermia and oligospermia?
azospermia = no sperm oligospermia = reduced sperm
Which tests to do for male infertility?
LH FSH PRL Morning fast testosterone Sex hormone binding globulin - SHBG Albumin, iron studies pituitary/thyroid profile Karyotyping
*also do urine and chlamydia swab
What imaging to do for male infertility?
- Scrotal US/doppler for varicocoele/obstruction, testicular volume
- MRI pituitary if low LH FSH or high PRL
What treatment is offered for male infertility?
lifestyle : optimise BMI, smoking cessation, alcohol reduction/cessation
Specificly:
- dopamine agonist for hyperPRL
- Gonadotrophin treatment for fertility
- Testosterone if no fertility is required
- Surgery e.g. micro testicular sperm extraction
What is POI and what can cause it?
Premature ovarian insufficiency
Same symptoms as menopause
Conception can happen in 20%
To diagnose find FSH is high >25 , do this twice atleast 4 weeks apart
Autoimmune, genetic or cancer therapy causes
Which diseases can cause infertility in women with Low GnRH, Low LH FSH, low E2?
- Congential hypogondotrophic hyogonadism
: Anosmic (Kallmans) or normosmic - Acquired hypogonadotrophic hypogonadism - Low BMI, XS exercise, stress
- HyperPRL
Which diseases can cause just low LH FSH and Low E2?
Hypopiuitarism: tumour, infiltration, apoplexy, surgery, radiation
Which diseases can cause high LH FSH normal or low E2?
PCOS - polycystic ovarian syndrome
Which diseases can cause high LH FSH low E2?
Acquired primary hypogonadism, ( hypergonadotrophic )
POI
Congential primary hypogonadism e.g. turners, POI
How is polycystic ovarian syndrome diagnosed?
Rotterdam PCOS diagnostic criteria
- oligo or anovulation: Normally assessed by menstrual frequency as oligomenorrhoea: <21d or >35d cycles <8-9 cycles/y >90d for any cycle
If necessary anovulation can be proven by:
Lack of progesterone rise or US
- Clinical +/- biochemical hyperandrogenism:
CLINICAL
Acne, hirsutism (Ferriman-Gallwey score), alopecia (Ludwig score)
BIOCHEMICAL Raised androgens (eg Testosterone)
- Polycystic ovaries:
≥20 follicles OR ≥10ml either ovary on TVUS (8 MHz)
Do not use US until 8y post-menarche (due to high incidence of multi-follicular ovaries at this stage)
How to treat PCOS ?
for irregular/amenorrhoea:
oral contraceptive pill
for insulin resistance increase:
metformin
for hirsutism: creams,waxing,laser.
anti-androgens
what are the physical manifestations of turners syndrome?
short low hairline shield chest wide spaced nipples short 4th metacarpel small fingernails brown nevi amenorrhoea Underdeveloped reproductive tract
elbow deformity poor breast development coarctation of aorta webbed neck c
How to take a history for female infertility?
including duration, previous children, pubertal milestones, breastfeeding?,
Menstrual History: oligomenorrhoea or 1/20 amenorrhoea, associated symptoms (eg. E deficiency, PRL symptoms, CHH features), medical & surgical history, family history, social history, medications/drugs
How to examine for female infertility?
including BMI, sexual characteristics, hyperandrogenism signs, pelvic examination, other endocrine signs, syndromic features, anosmia
What blood tests to do for female infertility?
LH, FSH, PRL
Oestradiol, Androgens
Foll phase 17-OHP, Mid- Luteal Prog
Sex Hormone Binding Globulin (SHBG)
Albumin, Iron studies
Also Pituitary/Thyroid profile
Karyotyping
What tests to do for female infertility?
pregnancy hcg
urine test
chlamydia swab
what imaging to do for. female infertility?
US (transvaginal)
Hysterosalpingogram
MRI Pituitary
(if low LH/FSH or high PRL)
