INFERTILITY Flashcards
What is the definition of infertility?
A disease of the reproductive system defined by the failure to achieve a clinical pregnancy after >= 12 months of regular unprotected sex
What is the difference between primary and secondary infertility?
Primary - no live births previously
Secondary - have had a live birth > 12 months previously
What is the proportion of couples who have infertility?
1 in 7 but then half of these will conceive in the next 12 months
What are the costs of infertility to society?
Less births
Less tax income
Investigation costs
Treatment costs
What is a pre-testicular cause of infertility in men?
Congenital and acquired endocrinopathies
e.g. Kilinefelters
What are the testicular causes of infertility in men?
Congenital Cryptorchidism Infection (STDs) Immunological (antisperm antibodies) Vascular (varicocoele) Trauma/surgery Toxins (chemo/drugs/smoking)
What are some post-testicular causes of infertility in men?
Congenital
Obstructive azoospermia
Erectile dysfunction (retrograde ejaculation, mechanical impairment)
Latrogenic (vasectomy)
What is cryptorchidism?
Undescended testes through inguinal canal
List the 5 causes of infertility in women
- Ovarian causes
- Tubal causes
- Uterine causes
- Cervical causes
- Pelvic causes
What is endometriosis?
Presence of functioning endometrial tissue outside the uterus which responds to oestrogen
What are the symptoms of endometriosis?
Increased menstrual pain
Menstrual irregularities
Deep dyspareunia (painful intercourse)
Infertility
What are the treatments for endometriosis?
Hormonal (e.g. OCP, progesterone)
Laparascopic ablation
Hysterectomy
Bilateral salpingo-oophorectomy (take out affected area)
What are fibroids?
Benign tumours of the myometrium which respond to oestrogen
What are symptoms of fibroids?
Usually asymptomatic Increased menstrual pain Menstrual irregularities Deep dyspareunia (painful intercourse) Infertility
What are the treatments for fibroids?
Hormonal (e.g. OCP, progesterone, GnRH agonists)
Hysterectomy
What causes hypogonadotrophism, hypogonadism and low GnRH in male infertility?
Congenital hypogonadotrophic hypogonadism
e.g. Kallmann syndrome (anosmic)
Acquired hypogonadotrophic hypogonadism
e.g. low BMI, XS exercise, stress
Hyperprolactinaemia
What causes hypogonadotrophism and hypogonadism in male infertility?
Hypopituitarism e.g. tumour, infiltration, apoplexy, surgery, radiation
What causes hypergonadotrophism and hypogonadism in male infertility?
Congenital primary hypogonadism
e.g. Klinefelters
Acquired primary hypogonadism
e.g. cryptorchidism, trauma, chemo, radiation
What is Kallmann syndrome and what does it present as?
Failure of migration of GnRH neurones with the olfactory fibres (from olfactory placode to hypothalamus)
Anosmia
Cryptorchidism
Failure of puberty e.g. micropenis, primary amenorrhoea
Infertility
What does hyperprolactinaemia inhibit and cause?
Kisspeptin neurones causing low GnRH/LH/FSH/T/Oest
Oligo/amenorrhoea
Low libido
Infertility
Osteoporosis
What is the chromosomal abnormality in Klinefelter syndrome?
XXY sex chromosome in men
What are the symptoms of Klinefelter syndrome?
Tall stature Little facial hair Breast development Female-type pubic hair development Mildly impaired IQ Narrow shoulders Wide hips Small penis and testes Low bone density Infertility
What investigations can you undertake with infertile men?
Semen analysis (volume, sperm conc., motility) LH/FSH/PRL blood test Morning fasting testosterone Sex hormone binding globulin test Karyotyping Pituitary/thyroid profile Urine test MRI for pituitary Scrotal ultrasound
What are 3 lifestyle treatments for male infertility?
optimise BMI
Smoking cessation
Alcohol reduction
What are specific treatments for male infertility?
Dopamine agonist for hyperprolactinaemia
Gonadotrophin treatment for fertility
Testosterone if no fertility is required
Surgery
List all the categories causes of female infertility
Tubal causes Uterine causes Cervical causes Ovarian causes Pelvic causes Idiopathic
What are some tubal causes of female infertility?
Infection
Endometriosis
Trauma
What are some uterine causes of female infertility?
Chronic endometritis (Tb)
Fibroid
Adhesions
Congenital malformation
What are some cervical causes of female infertility?
Ineffective sperm penetration:
- Chronic cervicitis
- Immunological (antisperm Ab)
What are some ovarian causes of female infertility?
Anovulation
Corpus luteum insufficiency
What are some pelvic causes of female infertility?
Endometriosis
Adhesions
What is amenorrhoea?
No periods for at least 3-6 months
Or
Up to 3 periods a year
What is primary amenorrhoea?
Later than 16 years old regarded as abnormal
What is secondary amenorrhoea?
Periods start but then stop for 3-6 months
What is oligomenorrhoea?
Irregular or infrequent periods > 35 day cycles
Or
Up to 4-9 cycles per year max
What is premature ovarian insufficiency (POI)?
Early menopause previously called premature ovarian failure (POF). Conception can still occur in 20%
What is the diagnosis of premature ovarian insufficiency (POI)?
High FSH > 25 iU/L (x2 at least 4 weeks apart)
What are the causes of premature ovarian insufficiency (POI)?
Autoimmune
Genetic e.g. fragile X syndrome, Turner’s syndrome
Cancer therapy (radio/chemo in past)
What causes low GnRH, hypogonadotrophism and hypogonadism in women?
Congenital hypogonadotrophic hypogonadism
- Anosmic (Kallmann syndrome) or normosmic
Acquired hypogonadotrophic hypogonadism
- Low BMI, XS exercise, stress
Hyperprolactinaemia
What causes hypogonadotrophism and hypogonadism in women?
Hypopituitarism e.g. tumour, apoplexy, surgery, radiation
What causes hypergonadotrophism and hypogonadism in women?
Polycystic ovarian syndrome (PCOS)
Acquired primary hypogonadism:
- POI
- surgery, trauma, radiation, chemo
Congenital primary hypogonadism:
- Turner’s syndrome
- POI
What is the epidemiology of PCOS?
Affects 5-15% of women of reproductive age
Frequent family history
Most common endocrine disorder in women and cause of infertility of women
How do you diagnose PCOS and explain it
Exclude other reproductive disorders then…
Rotterdam PCOS diagnostic criteria (2/3) - Oligomenorrhoea/anovulation - Clinical signs of (with/out biochemical) hyperandrogenism - Polycystic ovaries
Which combination of diagnostic criteria gives the worst metabolic risk?
Oligomenorrhoea/anovulation
Clinical signs of (with/out biochemical) hyperandrogenism
How is PCOS treated?
Patient is asked which symptoms they want to get rid of and tailored treatment plan is drawn up
If a PCOS patient wishes to remove oligo/amenorrhoea and thus infertility as a symptom what can they take?
Oligo/amenorrhoea:
- Oral contraceptive pill
- Metformin
Infertility:
- Clomiohene
- Letrozole
- IVF
If a PCOS patient wishes to remove impaired glucose homeostasis (T2DM) as a symptom what can they do?
Metformin
Diet + lifestyle
If a PCOS patient wishes to remove hirsutism as a symptom what can they take?
Anti-androgens e.g. spironolactone
Creams, waxing, laser
If a PCOS patient wishes to remove an increased endometrial cancer risk as a symptom what can they take?
Oral contraceptive pill
Progesterone courses
What are the symptoms of Turner’s syndrome?
Short stature Low hairline Shield chest Wide spaced nipples Small fingernails Brown nevi Webbed neck Coarctation of aorta Poor breast development Elbow deformity Underdeveloped reproductive tract Amenorrhoea
What are the blood tests that can be done to investigate female infertility?
LH, FSH, PRL Oestradiol, androgens Mid-luteal progesterone Sex hormone binding globulin (SHBG) Albumin, iron studies Pituitary/thyroid profile Karyotyping
What are some microbiological tests that can be done to investigate female infertility?
Urine test
Chlamydia swab
What are some imaging techniques that can be done to investigate female infertility?
Transvaginal ultrasound
Hysterosalpingogram
MRI pituitary if hypogonadotrophism or hyperprolactinaemia
