Infertility Flashcards
What is inferility?
A disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months of regular unprotected sexual intercourse
(every 2-3 days = regular intercourse)
What is primary infertility?
When have no had a live birth previously
What is secondary infertility?
When have had a live birth more than 12 months previously
How common is infertility in couples?
1 in 7
Half of these will conceive in the next 12 months (in 24 months - 7% of couples are infertile)
What are the psychological distresses of infertility?
No biological child Impact on couples wellbeing Impact on larger family Investigations treatments (failure)
What is the cost to society due to infertility?
Fewer births
Less tax income
Investigation costs
Treatment costs
What are the main pre-testicular causes of infertility?
Congenital and acquired endocrinopathies (Kleinfelters - 47XXY), Y chromosome deletion, HPG, PRL (prolactinoma)
What are the main testicular causes of infertility?
Cryptorchidism Infection (STDs) Immunological (Antisperm antibodies) Vascular (varicoele) Trauma/surgery Toxins
What are the main post-testicular causes of male infertility?
Absence of vas deferens in patients with cystic fibrosis
Obstructive azoospermia
Erectile dysfunction
Latrogenic- vasectomy
What is the function of the vas deferens?
Transports mature sperm from the epididymis to the urethra in preparation for ejaculation
What are the three main types of erectile dysfunction?
Retrograde ejaculation
Mechanical impairment
Psychological
What is retrograde ejaculation?
The semen within the urethra travels back into the bladder.
What is cryptorchidism?
There is undescended testis in the inguinal canal. into the scrotum.
What is the main cause of infertility in females?
Ovarian causes (anovulation, and a corpus luteum insufficiency)
Which hormone is mainly secreted by the corpus lutuem?
Progesterone
Shat are the five main types of female infertility causes?
1) Ovarian causes
2) Tubal causes
3) Uterine causes
4) Cervical causes (ineffective sperm penetration due to chronic cervicitis) and antisperm ABs
5) Pelvic causes (endometriosis and adhesions)
What is endometriosis?
a condition resulting from the appearance of functioning endometrial tissue outside the uterus and causing pelvic pain,
What are the symptoms of endometriosis?
Menstrual pain
Menstrual irregularities
Deep dyspareunia (Pain during sexual intercourse)
infertility
Why do individuals with endometriosis experience menstrual pain?
Endometrial tissue responds to oestrogen in a cyclic manner.
What are the treatments for endometriosis?
Hormonal (continuous OCP, progesterone) Laparscopic ablation (removal of endometrial tissue) Hysterectomy Bilateral salpingo-oophorectomy Moves ovaries and tubes
What are fibroids?
Benign tumours of the myometrium that respond to oestrogen
What are the symptoms of fibroids?
Asymptomatic usually Increased menstrual pain Menstrual irregularities Deep dyspareunia Infertility
What are the treatments available for fibroids?
Hormonal (Continuous OCP, progesterone, continuous GnRH agonist)
Hysterectomy
Which neurones control the pulsatile secretion of gonaodtropins?
Kisspeptin neurones
Which endocrine cells secrete LH and FSH?
Gonadotrophs within the anterior pituitary gland
Which hormones are released from the gonads
Inhibin, activin, oestrogen, testosterone, progesterone
Which enzyme converts testosterone to oestrogen?
Aromatase
What type of feedback is exerted by oestrogen on the hypothalamic pituitary gonadal axis?
Negative feedback on anterior pituitary secretion of gonaodtropins and hypothalamic neurones
What effect does prolactin have on kisspeptin neurones?
Inhibits kisspeptin neurones and thus decreases pulsatile action of GnRH secretion from hypothalamic neurones, This causes a downstream inhibition on LH and FSH release from the anterior pituitary gonaodtrophs, as well as testosterone release from the testes.
Which hormones are insufficient in a patient with hyperprolactinaemia?
LH, FSH and testosterone
What type of hypogonadism is Klinefelters syndrome?
Primary hypogonadism, there is an insufficient secretion of testosterone from the testes.
What impact does Klinefelters syndrome have on LH and FSH levels?
Dysregulation of negative feedback system, stimulating increased secretion of LH and FSH due to low testosterone.
What is Kallman’s syndrome?
Hypogonadotrophic hypogonadism, in addition to anosmia
What are the three forms of acquired hypogonadotrophic hypogonadism?
Low BMI (Anorexia can cause hypothalamic suppression)
Excess exercise
Stress
What are the common causes of hypopituitarism?
Tumour, infiltration, apoplexy, surgery and radiation
Which hormones are deficient in congenital and acquired hypogonadotrophic hypogonadism, and hyperprolactinaemia?
GnRH (Not measurable)
LH
FSH
Testosterone
What type of hypogonadism is Klinefelters syndrome?
Hypergonadotrophic hypogonadism
How does Kallmann syndrome cause male infertility?
There is failure of migration of GnRH neurones with olfactory fibres to the hypothalamus, therfore leading to a hypogonaodtrophic hypogonadism as there is a failure to secrete GnRH
What are the clinical features of Kallman syndrome?
Anosmia Cryptorchidism Failure of puberty Lack of testicle development Micropenis Primary amenorrhoea Infertility
What agonists can be prescribed to treat hyperprolactinaemia?
Dopamine agonists (cabergoline)
Dopamine inhibits prolactin release from lacotrophs.
What is the available treatment for individuals with hyperprolactinaemia?
Dopamine agonists (cabergoline)
Transsphenoidal surgery
Sellar radiotherapy
What are the causes of hyperprolactinaemia?
Prolactinoma (micro/macro) Pituitary stalk compression Pregnancy & breast feeding Medication (dopamine antagonists, including anti-emetics and antipsychotics) Oestrogens (OCP)
PCOS and hypothyroidism
What are the clinical features of Klinefelters syndrome?
Tall stature Decreased facial hair Breast development Female-type pubic hair pattern Small penis and testes Infertility Mildly impaired IQ Narrow shoulders Reduced chest hair wide hips low bone density
What is examined during a medical examination of a patient with suspected Klinefelters syndrome?
BMI Sexual characteristics Testicular volume Epididymal hardness Presence of vas deferens
What is the normal testicular volume for a male?
50ml
What happens to testicular volume in a patient with Klinefelter’s syndrome?
Low testicular volume (1.5ml)
What should be measured in a blood test of a patient with suspected Klinefelter’s syndrome?
LH FSH and PRL
Morning fasting testosterone
Sex hormone binding globulin (SHBG)
Albumin, iron studies (Iron deposition can affect pituitary function)
Pituitary/thyroid profile (Thyroid hormone can affect bioavailable testosterone)
Karyotyping
What is varicocoele?
A varicocele is an enlargement of the veins within the scrotum. Varicoceles are a common cause of low sperm production and decreased sperm quality, which can cause infertility.
When should a pituitary MRI be conducted in a patient with hypogonadism?
If there is low LH/FSH or high prolactin
What general lifestyle changes can be done to improve male fertility?
1) Optimise BMI
2) Smoking cessation
3) Alcohol reduction/cessation
What treatment is available for male infertility?
1) Dopamine agonists for hyperprolactinaemia
2) Gonadotrophin treatmnt for fertility (will also increase testosterone).
3) Testosteorne (for symptoms if no fertility is required)
4) Surgery (micro testicular sperm extraction)
What is the initial test that should be conducted for a patient presenting with female inferility?
Pregnancy test (beta-hcg)
What is primary amenorrhoea?
The absence of menarche by age 16
What is secondary ammenorrhoa?
Irregular periods, anovulatory for first 18 months.
Periods START but cease for 3-6 month minimum.
What is ammenorrhoea?
No periods for at least 3-6 months
Or up to 3 periods a year
What is oligo-menorrhoea?
Irregular or infrequent periods >35 day cycle
4-9 cycles per year
What is the hormone profile in a patient with premature ovarian insufficiency?
LH and FSH are elevated
Oestradiol decreased
The ovaries fail to release oestrogen
What are the clinical symptoms presented in patients with a premature ovarian insufficiency?
Menopause before the age of 40 hot flushes sleep disturbances infertility Vaginal dryness and atrophy High FSH > 25iU/L (x2 at least 4wks apart)
What is the hormone pattern in a female patient with anorexia nervosa-induced amenorrhoea?
There is hypogonadotrophic hypogonadism
Low FSH/LH and low oestradiol
There is low leptin which feedback on kisspeptin neurones to reduce pulsatility.
What are two main examples of congenital primary hypogonadism?
Turner’s syndrome
Premature ovarian insufficiency
What criteria is used to diagnose a patient with PCOS?
Rotterdam PCOS diagnostic criteria (2 of 3)
What are the three criterions for PCOS?
Oligo or anovulation
Clinical/biochemical hyperandrogenism
Clinical (Acne, hirsutism, alopecia)
Polycystic ovaries (>20 follicles)
What are the associated risks with PCOS?
Increased insulin resistance (impaired glucose homeostasis, T2DM, gestational DM)
Hirsutism
Increased endometrial cancer risk
Infertility (irregular menses)
What treatment can be prescribed to treat female infertility?
Clomiphene
Letrozole
IVF
What drug can be prescribed to PCOS patients with increased insulin resistance?
Metformin
What drug can be prescribed as an anti-androgen?
Spironolactone
What are the clinical features in a patient with Turner’s syndrome (45X0)?
Short stature Low hairline Shield chest Wide spaced nipples Short 4th metacarpal small fingernails Brown nevi Characteristic facies Webbed neck Coarctication of aorta Poor breast development Elbow deformity Underdeveloped reproductive tract AmenORRHOEA.
