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Reproduction Year 3 > Infertility > Flashcards

Infertility Flashcards

1
Q

Infertility

A

the failure to conceive after one year or more of frequent, unprotected sexual intercourse

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2
Q

What percentage of couples in the UK are affected by infertility?

A

1 in 7 couples (15%)

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3
Q

What are the 2 classifications of infertility?

A
  1. Primary

2. Secondary

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4
Q

What is primary infertility?

A

couples who have never conceived

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5
Q

What is secondary infertility?

A

couples who have previously conceived

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6
Q

Hypothalamic-pituitary-gonadal (HPG) axis

A

The hypothalamus releases gonadotrophin-releasing hormone (GnRH). GnRH acts on the anterior pituitary to stimulate the secretion of follicle-stimulating hormone (FSH) and luteinising hormone (LH).

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7
Q

What are the 4 causes of infertility in the UK?

A

Male factor infertility (30%)
Ovulatory causes for infertility (25%)
Tubal causes for infertility (20%)
Uterine/peritoneal causes for infertility (10%)

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8
Q

What does the release of LH and FSH from the anterior pituitary do in females?

A

LH and FSH then stimulate the ovaries to produce progesterone and oestrogen. When there are moderate levels of oestrogen, negative feedback on the HPG axis inhibits GnRH release.

However, when there are high levels of oestrogen present, positive feedback on the HPG axis stimulates the hypothalamus to secrete GnRH.

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9
Q

What does the release of LH and FSH from the anterior pituitary do in males?

A

LH acts on Leydig cells within the testes to produce testosterone. Testosterone and FSH then interact with Sertoli cells to stimulate sperm development. Testosterone also provides negative feedback to the hypothalamus to suppress GnRH secretion.

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10
Q

Female factor infertility can be separated into 3 categories; what are they?

A

Disorders of ovulation
Tubal causes
Uterine/peritoneal causes

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11
Q

There are 3 main types of ovulatory disorders; what are they?

A

Group I – hypothalamic-pituitary failure
Group II – hypothalamic-pituitary-ovulation dysfunction
Group III –ovarian failure

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12
Q

What is the name of the Group 1 ovulatory disorder?

A

Group I – hypothalamic-pituitary failure

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13
Q

What is the name of the Group 2 anovulatory disorder?

A

Group II – hypothalamic-pituitary-ovulation dysfunction

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14
Q

What is the name of the Group 3 anovulatory disorder?

A

Group III –ovarian failure

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15
Q

What causes the Group I anovulatory disorders in infertility?

A

Group I – hypothalamic-pituitary failure

Hypogonadotropic hypogonadism: There is a failure to produce the required amount of LH and FSH, or GNRH resulting in anovulation.

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16
Q

What causes the Group II anovulatory disorders in infertility?

A

Group II – hypothalamic-pituitary-ovulation dysfunction

This occurs as the result of polycystic ovary syndrome (PCOS) – the most common cause of female infertility.

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17
Q

What causes the Group III anovulatory disorders in infertility?

A

Group III –ovarian failure

Hypergonadotropic hypogonadism: There is normal hypothalamic and pituitary function but there are insufficient numbers of follicles within the ovary. Therefore, there is less oestrogen produced and follicles do not develop fully. This results in anovulatory cycles.

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18
Q

Apart from the Group I, II & III anovulatory disorders, what are other causes of anovulation (female factor infertility)

A

Sheehan’s syndrome
Hyperprolactinaemia
Pituitary tumours

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19
Q

What is Sheehan’s syndrome?

A

Hypopituitarism caused by ischaemic necrosis of the pituitary. This occurs as the result of severe hypotension or haemorrhagic shock secondary to massive post-partum haemorrhage.

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20
Q

How does hyperprolactinaemia cause anovulation and thus infertility?

A

This inhibits both FSH and LH secretion and can lead to menstrual dysfunction and galactorrhoea (excessive production of milk)

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21
Q

How do Pituitary tumours cause anovulation and thus infertility?

A

The tumour displaces or destroys normal pituitary tissue and can affect the production of FSH and LH

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22
Q

What is the most common cause of tubal damage? (infertility cause)

A

The delicate structure of the fallopian/uterine tubes makes them more susceptible to damage.

The most common cause of tubal damage is due to pelvic inflammatory disease, which is usually secondary to chlamydia or gonorrhoea infection.

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23
Q

Apart from PID as a cause of tubal damage and thus tubal infertility, what are the other causes of tubal infertility?

A

Previous sterilisation
Endometriosis
Previous pelvic surgery

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24
Q

Endometriosis

A

Inner lining of uterus (endometrium) tissue grows outside the uterus/womb

25
Q

What is the most common cause of Uterine/peritoneal causes of female infertility?

A

Endometriosis, which causes inflammation and adhesions in the pelvis that can distort pelvic anatomy.

26
Q

Apart from endometriosis as the most common cause of Uterine/peritoneal causes of female infertility; what are some other causes?

A
  1. Cervical mucus dysfunction or defect
  2. Previous pelvic or cervical surgery
  3. Uterine fibroids
  4. Asherman’s syndrome
  5. Previous abdominal infections (e.g. appendicitis)
  6. Congenital abnormalities
27
Q

Asherman’s syndrome

A

An acquired uterine condition that occurs when scar tissue form inside the uterus and/or the cervix. It is characterized by variable scarring inside the uterine cavity, where in many cases the front and back walls of the uterus stick to one another.

28
Q

How is male factor infertility diagnosed?

A

Semen analysis

29
Q

Oligospermia

A

< 15 million sperm per ml (low sperm count)

30
Q

Teratospermia

A

< 4% normal morphology (abnormal sperm morphology)

31
Q

Asthenospermia

A

< 32% sperm motility (immobile sperm)

32
Q

Azoospermia

A

No sperm found within the ejaculate

33
Q

Male factor infertility can be divided into 3 classifications; what are they?

A

1) Obstructive infertility
2) Non-obstructive infertility
3) Coital infertility

34
Q

What is Obstructive infertility in males?

A

a problem with the sperm delivery

35
Q

What is Non-obstructive infertility in males?

A

a problem with the sperm production

36
Q

What is Coital infertility in males?

A

Infertility secondary to sexual dysfunction

37
Q

What are the causes of obstructive infertility in males?

A

Previous vasectomy
Cystic fibrosis
Ejaculatory duct obstruction
Epididymal obstruction

38
Q

What are the causes of non-obstructive infertility in males?

A
  1. Hormonal causes
  2. Varicocele
  3. Genetic causes:
  4. Cryptorchidism
  5. Previous testicular trauma or damage (e.g. testicular torsion)
  6. Testicular malignancy
39
Q

What are the causes of coital infertility in males?

A
  1. Erectile dysfunction
  2. Premature ejaculation
  3. Anejaculation:
  4. Retrograde ejaculation
  5. Penile deformities
40
Q

What does the vas deferens do?

A

Carry sperm from epididymis where it’s stored to ejaculatory ducts

41
Q

How does ejaculatory duct obstruction cause obstructive type male factor infertility?

A

Can be caused by previous prostatitis, leading to fibrosis of the ejaculatory duct or by congenital prostatic cysts

42
Q

How does ejpididymal obstruction cause obstructive type male factor infertility?

A

May occur secondary to a chlamydia or gonorrhoea infection which can cause inflammation and fibrosis of the epididymis – sperm is stored in epididymis before being transported via vas deferens to ejaculatory ducts – blockage of epididymis stops transport of sperm

43
Q

What are the hormonal causes of non-obstructive male factor infertility?

A

hypogonadotropic hypogonadism, hyperprolactinaemia – causes infertility secondary to impotence

44
Q

Varicocele

A

Is associated with impaired testicular function and infertility

45
Q

What are the genetic causes of non-obstructive male factor infertility?

A

Klinefelter’s syndrome (47, XXY)
Androgen insensitivity syndrome
Kallmann syndrome

46
Q

Cryptorchidism

A

(undescended testes)

47
Q

What are the two types of Anejaculation (no ejaculation)?

A

o Primary – may occur due to psychosexual or neurological causes

o Secondary – may occur due to previous abdominal/pelvic surgery or certain drugs such as antidepressants or alpha-blockers

48
Q

Retrograde ejaculation

A

goes into bladder instead of penis

49
Q

What are the penile deformities that cause coital male factor infertility?

A

e.g. Peronei’s disease (scar tissue grows under skin of penis) & hypospadias (the opening of the urethra is not located at the tip of the penis).

50
Q

Peronei’s disease

A

car tissue grows under skin of penis

51
Q

Hypospadias

A

the opening of the urethra is not located at the tip of the penis

52
Q

What are the investigations for male factor infertility?

A
  1. Semen analysis

2. Chlamydia screen

53
Q

What are the investigations for female factor infertility?

A
  1. Mid-luteal progesterone (day 21 or equivalent cycle)
  2. FSH and LH to assess ovarian function
  3. Chlamydia screen
54
Q

What are the initial preconception lifestyle advice, which ideally would be given in primary care?

A
  1. Encourage regular intercourse – every 2-3 days
  2. 400 micrograms folic acid daily(take 5mg daily if high risk for neural tube defects e.g. diabetes, on anti-epileptics etc.)
  3. Smoking cessation
  4. Reduce alcohol intake if excessive
  5. Optimise weight
  6. Healthy diet and regular exercise
  7. Men to wear loose-fitting clothing
55
Q

How much folic acid should be given in preconception?

A

400 micrograms folic acid daily(take 5mg daily if high risk for neural tube defects e.g. diabetes, on anti-epileptics etc.)

56
Q

What is the MEDICAL management for infertility in females?

A

Clomiphene
Gonadotrophins
Pulsatile GnRH
Dopamine agonists

57
Q

What is the MEDICAL management for infertility in females?

A

Clomiphene
Gonadotrophins
Pulsatile GnRH
Dopamine agonists

58
Q

How does Clomiphene induce ovulation (infertility medication)?

A

Is an anti-oestrogen drug:

Induces ovulation by inhibiting oestrogen from binding in the anterior pituitary.

Stops the negative feedback mechanism of oestrogen, thus the secretion of GnRH, FSH and LH increases. Results in greater stimulation of the ovaries and therefore a greater increase in oestrogen production and secretion. The oestrogen stimulates follicle growth and maturation.

59
Q

What is the SURGICAL management for infertility in females?

A

Tubal surgery: Used for women with mild tubal disease

Reproduction Year 3 (17 decks)

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