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BRS YR2 > Infertility > Flashcards

Infertility Flashcards

1
Q

What is infertility?

A

The failure to achieve a clinical pregnancy after >12 months of regular, unprotected sexual intercourse

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2
Q

What is primary infertility?

A

When the person has NOT had a live birth previously

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3
Q

What is secondary infertility?

A

When they have had a live birth, conceiving after more than 12 months of regular, unprotected sex

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4
Q

How common is infertility?

A

1/7 couples affected

half will conceive in the following 12 months

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5
Q

How often do struggling couples seek help?

A

55%*

* positive association with socioeconomic status

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6
Q

What are the most common causes of infertility in a couple?

A
  • male factor (30%)
  • female factor (30%)
  • combined male and female factor (30%)
  • unknown factor (10%)
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7
Q

What is the impact of infertility on the couple?

A
  • psychological distress to the couple
  • no biological child
  • impact on the couples wellbeing
  • impact on the larger/extended family
  • investigations
  • treatments (can be costly, often fail)
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8
Q

What is the impact of infertility on society?

A
  • less births
  • less tax income
  • investigation costs
  • treatment costs
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9
Q

What are pre-testicular causes of male infertility?

A

Congenital and acquired endocrinopathies

  • klinefelters
  • Y chromosome deletion
  • HPG, T, PRL
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10
Q

What are testicular causes of male infertility?

A
  • Congenital
  • Cryptorchidism
  • Infections (STIs)
  • Immunological (Antisperm Abs)
  • Vascular (Varicocoele)
  • Trauma/surgery
  • Toxins (Chemo, DXT, Drugs, Smoking)
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11
Q

What are post-testicular causes of male infertility?

A
  • Congenital (no vans deferens in CF)
  • Obstructive Azoospermia
  • Erectile Dysfunction (Psychological, Retrograde Ejaculation, Mechanical Impairment)
  • Iatrogenic (Vasectomy)
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12
Q

What is Crytorchidism?

A

Undescended testes (90% in the inguinal canal)

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13
Q

What are the pelvic causes of infertility in women?

A

(5%)

  • endometriosis
  • adhesions
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14
Q

What are tubal causes of infertility in women?

A 
(30%)
Tubopathy due:
- infection 
- endometriosis
- trauma
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15
Q

What are ovarian causes of infertility in women?

A

(40%)

  • anovulation (endo)
  • corpus luteum insufficiency
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16
Q

What are the cervical causes of infertility in women?

A

(5%)
Ineffective sperm penetration due to:
- chronic cervicitis
- immunological (antisperm Ab)

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17
Q

What are the uterine causes of infertility in women?

A 
(10%)
Unfavourable endometrium due to:
- chronic endometritis (TB)
- fibroid
- adhesions (synechiae)
- congenital malformation
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18
Q

What is endometriosis?

A
  • presence of functioning endometrial tissue outside of the uterus, that responds to Oestrogen
    (5% of women)
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19
Q

What are the symptoms of endometriosis?

A
  • increased menstrual pain
  • menstrual irregularities
  • deep dyspareunia
  • infertility
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20
Q

What are the treatments available for endometriosis?

A
  • hormonal (continuous OCP, progesterone)
  • laprascopic ablation
  • hysterectomy
  • bilateral salpingo-oophorectomy
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21
Q

What are fibroids?

A

Benign tumours of the myometrium, responds to oestrogen

1-20% of per-menopausal women - increases with age

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22
Q

What are the symptoms of fibroids?

A

Usually asymptomatic

  • increased menstrual pain
  • menstrual irregularities
  • deep dyspareunia
  • inferility
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23
Q

What are the treatments available for fibroids?

A
  • Hormonal (continuous OCP, progesterone, continuous GnRH agonists)
  • Hysterectomy
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24
Q

What are the secretion patterns of GnRH and LH?

A

pulsatile

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25
Q

What are the secretion patterns of sex steroids?

A

diurnal rhythm

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26
Q

What are the clinical presentations of Turners Syndrome?

A

Hypergonadotrophic
(high LH and FSH)
Hypogonadism
(low testosterone)

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27
Q

How common is Turners Syndrome?

A

1/2500 live female births

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28
Q

What are the symptoms of Turners Syndrome?

A
  • short
  • low hairline
  • shield chest
  • characteristic facies
  • webbed neck
  • coarctation of aorta
  • poor breast development
  • elbow deformity
  • underdeveloped reproductive tract
  • amenorrhoea
  • brown nevi
  • short 4th metacarpal
  • wide-spaced nipples
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29
Q

What should the history for female infertility include?

A 
Hx of PC:
- duration?
PMHx:
- previous children, breastfeeding?
- pubertal milestones
- menstrual history (oligomenorrhoea, associated symptoms)
- medical and surgical history
Family Hx
Social Hx
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30
Q

What should be included in an examination for female infertility?

A
  • BMI
  • sexual characteristics
  • hyperadrenogenism signs
  • pelvic exam
  • syndromic features
  • anosmia
  • other endocrine signs
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31
Q

What are the main investigations done for female infertility?

A 
Blood tests
Preganancy test (urine or serum HCG)
Urine test
Chlamydia swab
Ultrasound (transvaginal)
Hysterosalpingogram
MRI pituitary (if low LH/FSH or high PRL)
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32
Q

Which blood tests should be done when concerned about female infertility?

A
  • LH, FSH, PRL
  • Oestradiol, Androgens
  • Follicular phase 17-OHP
  • Mid-luteal progesterone
  • Sex hormone binding globulin (SHBG)
  • Albumin
  • Iron
  • Pituitary/thyroid profile
  • Karyotyping
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33
Q

How common is PCOS?

A
  • affects 5-15% of women of reproductive age
  • family history (frequent)
  • most common endocrine disorders in women
  • most common cause of infertility in women
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34
Q

Which criteria is used to diagnose PCOS?

A

The rotterdam PCOS diagnostic criteria (2/3)

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35
Q

What are the 3 factors of an PCOS diagnosis?

A
  • oligo or anovulation
  • clinical / biochemical hyperandrogenism
  • polycystic ovaries
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36
Q

How to assess oligo or anovulation in possible PCOS?

A

normally by menstrual frequency (oligomenorrhoea)

  • <21 days, or >35 day cycles
  • <8/9 cycles/year
  • > 90 days for any cycle

anovulation can be proved by: lack of progesterone rise or an Ultrasound

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37
Q

How to assess clinical/biochemical hyperandrogenism with possible PCOS?

A 
Clinical:
- acne
- hirsutism (Ferriman-Gallwey score)
- alopecia (ludwig score)
Biochemical
- raised androgen (testosterone)
38
Q

How to assess polycystic ovaries in possible PCOS?

A
  • > 20 follicles
  • > 10ml either ovary on TVUS (8MHz)

do NOT use ultrasound until 8 years post menarche due to high incidence of multi-follicular ovaries

39
Q

Which 2 red flags for PCOs have the worst metabolic risk as a combination?

A

Oligo/Anovulation, and clinical/biochemical hyperandrogenism

40
Q

What are the main presentations of PCOS?

A
  • Irregular menses/amenorrhoea
  • Infertility
  • increased insulin resistance
  • impaired glucose homeostasis (T2DM, gestational DM)
  • Hirsutism
  • Increased risk of endometrial cancer risk (2-6)
41
Q

How to treat the irregular menses/amenorrhoea caused by PCOS?

A

Oral contraceptive pill

Metformin

42
Q

How to treat the infertility caused by PCOS?

A
  • clomiphene
  • letrozole
  • IVF
43
Q

How to treat the increased insulin resistance caused by PCOS?

A

diet and lifestyle

44
Q

How to treat the hirsutism caused by PCOS?

A
  • cream, waxing, laser

- anti-androgens (spironolactone)

45
Q

How to manage the increased risk of endometrial cancer caused by PCOS?

A

progesterone courses

46
Q

What is the biochemical presentation of congenital hypogonadotrophic hypogonadism in females?

A
  • decreased GnRH
  • low FSH, LH (hypogonadotrophic)
  • low Oestradiol (hypogonadism)
47
Q

What is the biochemical presentation of acquired hypogonadotrophic hypogonadism in females?

A
  • decreased GnRH
  • low FSH, LH (hypogonadotrophic)
  • low Oestradiol (hypogonadism)
48
Q

What is the biochemical presentation of hyperprolactinaemia in females?

A
  • decreased GnRH
  • low FSH, LH (hypogonadotrophic)
  • low Oestradiol (hypogonadism)
49
Q

What is the biochemical presentation of hypopituitarism?

A
  • low LH, FSH (hypogonadotrophic)

- low E2 (hypogonadism)

50
Q

What is the biochemical presentation of PCOS?

A
  • high LH, FSH

- normal/low E2

51
Q

What causes congenital hypogonadotrophic hypogonadism?

A
  • Anosmic (Kallmann syndrome)

- Normosmic

52
Q

What are causes of acquired hypogonadotrophic hypogonadism?

A
  • low BMI
  • excess exercise
  • stress
53
Q

What are possible cuases of hypopituitarism?

A
  • tumour
  • infiltration
  • apoplexy
  • surgery
  • radiation
54
Q

What are are possible caused of acquired primary hypogonadism ?

A
  • POI (premature ovarian insufficiency)
  • Surgery
  • Trauma
  • Chemo
  • Radiation
55
Q

What are are possible caused of congenital primary hypogonadism ?

A
  • Turners syndrome

- Premature Ovarian Insufficiency (POI)

56
Q

What are the symptoms of Premature Ovarian Insufficiency?

A
  • same as menopause

- chance of conception: 20%

57
Q

How to diagnose POI?

A

High FSH >25iU/L

x 2, 4 weeks apart

58
Q

What are the causes of POI?

A
  • autoimmune
  • genetic (eg: Turners Syndrome)
  • cancer therapy (Radio/Chemo)
59
Q

What is primary amenorrhoea?

A

NO period ever

after 16 = abnormal

60
Q

What is secondary amenorrhoea?

A

Periods start, bu then storp for at least 6-12 months

normal to be irregular/anovulatory for first 18 months

61
Q

What is Amenorrhoea?

A
  • no periods for at least 3-6 months

- <3 periods per year

62
Q

What is Oligo-menorrhoea?

A
  • irregular of infrequent periods
  • > 35 day cycles
  • 4-9 cycles/year
63
Q

What are the possible lifestyle changes to treat male infertility?

A
  • optimise BMI
  • smoking cessation
  • alcohol reduction/cessation
64
Q

What are the specific treatments available for male infertility?

A
  • dopamine agonist (hyperPRL)
  • Gonadotrophin treatment for fertility (will increase testosterone)
  • Testosterone (for symptoms, NO fertility necessary)
  • Surgery (Micro Testicular sperm extraction)
65
Q

What should be part of a history for male infertility?

A 
Hx of PC:
- duration
- associated symptoms (PRL, T deficiency, CHH features)
PMHx:
- previous children
- pubertal milestones
- medications and drug
Family Hx
Social Hx
66
Q

What is included in an examination for suspected male infertility?

A
  • BMI
  • sexual characteristics
  • testicular volume
  • epididymal hardness
  • presence of vans deferens
  • syndromic features
  • anosmia
  • other endocrine signs
67
Q

What are the main investigations done when male infertility is suspected?

A
  • Urine test
  • Blood test
  • Chlamydia swab
  • Semen analysis
  • Scrotal Ultrasound / Doppler (obstruction, testicular volume)
  • MRI pituitary (if low LH, FSH or high PRL)
68
Q

What is involved in a blood test for possible male infertility?

A
  • LH, FSH, PRL
  • Morning fasting testosterone
  • Sex Hormone Binding Globulin (SHBG)
  • Albumin
  • Iron
  • Pituitary/Thyroid profile
  • Karyotyping
69
Q

What is Azospermia?

A

No sperm

70
Q

What is Oligospermia?

A

Low/Reduced sperm

71
Q

What is the biochemical presentation of Klinefelters Syndrome?

A
  • High LH, FSH (hypergonadotrophism)
  • Low Testosterone (Hypogonadism)
  • trisomy
72
Q

How common is Klinefelters Syndrome?

A

1/1100 live male births

73
Q

What are the symptoms of Klinefelters Syndrome?

A
  • Tall stature
  • Reduced facial hair
  • Breast development
  • Female-type pubic hair pattern
  • Small penis and testes
  • Infertility (3% of cases)
  • Impaired IQ (15 points lower)
  • Narrow shoulders
  • Reduced chest hair
  • Wide hips
  • Low bone density
74
Q

What is the impact of hyperprolactinaemia?

A
  • inhibits kisspeptin release, therefore reducing downstream GnRH, LH, FSH, Testosterone and Oestrogen
75
Q

What can hyperprolactinaemia cause?

A
  • Oligo/Amenorrhoea
  • Low libido
  • Infertility
  • Osteoporosis
76
Q

What is the treatment for hyperprolactinaemia?

A
  • Dopamine agonist (Cabergoline)

- Surgery/DXT

77
Q

What is Kallmann syndrome?

A

The failure of the migration of GnRH neurons with olfactory fibres

78
Q

What are the symptoms of Kallmann Syndrome?

A
  • Anosmia
  • Cryptochidism
  • Failure of puberty
  • Lack of testicle development
  • Micropenis
  • Primary Amenorrhoea
  • Infertility
79
Q

What are the biochemical features of Kallmann Syndrome?

A
  • Reduced GnRH
  • Low LH, FSH (hypogonadotrophic)
  • Low testosterone (hypogonadism)
80
Q

What are the biochemical characteristics of congenital primary hypogonadism in males?

A
  • high LH and FSH (hypergonadotrophic)

- low testosterone (hypogonadism)

81
Q

What are the biochemical characteristics of acquired primary hypogonadism in males?

A
  • high LH and FSH (hypergonadotrophic)

- low testosterone (hypogonadism)

82
Q

What are the causes of acquired primary hypogonadism in males?

A
  • Cryptochidism
  • Trauma
  • Chemo
  • Radiation
83
Q

What are the causes of congenital primary hypogonadism in males?

A
  • Klinefelters (47XXY)
84
Q

What are the biochemical characteristics of hypopituitarism in males?

A
  • low LH, FSH (hypogonadotrophic)

- low testosterone (hypogonadism)

85
Q

What are the causes of hypopituitarism in men?

A
  • tumour
  • infiltration
  • apoplexy
  • surgery
  • radiation
86
Q

What are the biochemical characteristics of congenital hypogonadotrophic hypogonadism in males?

A
  • Reduced GnRH
  • Reduced LH, FSH (hypogonadotrophic)
  • Reduced testosterone
    (hypogonadism)
87
Q

What are the biochemical characteristics of acquired hypogonadotrophic hypogonadism in males?

A
  • Reduced GnRH
  • Reduced LH, FSH (hypogonadotrophic)
  • Reduced testosterone
    (hypogonadism)
88
Q

What are the biochemical characteristics of hyperprolactinaemia in males in respect to infertility?

A
  • Reduced GnRH
  • Reduced LH, FSH (hypogonadotrophic)
  • Reduced testosterone
    (hypogonadism)
89
Q

What causes congenital hypogonadotrophic hypogonadism in males?

A
  • Anosmic (Kallmann Syndrome)

- Normosmic

90
Q

What causes acquired hypogonadotrophic hypogonadism in males?

A
  • Low BMI
  • Excess exercise
  • Stress

BRS YR2 (70 decks)

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