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BRS Phase 1b > Infertility > Flashcards

Infertility Flashcards

1
Q

What is infertility?

A

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

have not had a live birth previously

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3
Q

What is secondary infertility?

A

have had a live birth >12 months previously

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4
Q

How common is infertility?

A

Affects 1 in 7 of couples.
half will conceive within the next 12 months
55% will seek help, positive association with socio-economic status

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5
Q

What is the most common cause of infertility in a couple?

A

Male, Female and combination factors.

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6
Q

What are the pre-testicular causes of infertitility?

A

Congenital & Acquired Endocrinopathies
Klinefelters 47XXY
Y chromosome deletion
HPG, T, PRL

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7
Q

What are the testicular causes of infertility?

A 
(Congenital)
Cryptorchidism
Infection                       STDs
Immunological      Antisperm Abs
Vascular              Varicocoele
Trauma/Surgery
Toxins        
       Chemo/DXT/Drugs/Smoking
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8
Q

What are the post testicular causes of infertility?

A

Congenital Absence of vas deferens in CF
Obstructive Azoospermia
Erectile Dysfunction Retrograde Ejaculation Mechanical Impairment Psychological
Iatrogenic Vasectomy

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9
Q

What is cryptorchidism?

A

Undescended testis (90% in inguinal canal)

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10
Q

What are the ovarian causes of infertility?

A

40%

  • Anovulation (Endo)
  • Corpus luteum insufficiency
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11
Q

What are the tubal causes of infertility?

A 
30%
Tubopathy due: 
-Infection
-Endometriosis
-Trauma
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12
Q

What are the Uterine causes of infertility?

A 
10%
Unfavourable endometrium due:
-Chronic endometritis (TB)
-Fibroid
-Adhesions (Synechiae)
-Congenital malformation
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13
Q

What are the cervical causes of infertility?

A

5%
Ineffective sperm penetration due:
-Chronic cervicitis
-Immunological (antisperm Ab)

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14
Q

What are the pelvic causes of infertility?

A
  • Endometriosis

- Adhesions

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15
Q

What percentage of infertility is unexplained?

A

10%

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16
Q

What is endometriosis?

A

Presence of functioning endometrial tissue outside the uterus

  • 5% of women
  • Responds to oestrogen
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17
Q

What are the symptoms of endometriosis?

A

↑ Menstrual pain
Menstrual irregularities
Deep dyspareunia
Infertility

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18
Q

What is the treatment for endometriosis?

A

Hormonal (eg continuous OCP, prog)
Laparascopic ablation
Hysterectomy
Bilateral Salpingo-oophorectomy

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19
Q

What are Fibroids?

A

Benign tumours of the myometrium

  • 1-20% of pre-menopausal women (increases w age)
  • Responds to oestrogen
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20
Q

What are the symptoms of Fibroids?

A 
Usually asymptomatic
↑ Menstrual pain
Menstrual irregularities
Deep dyspareunia
Infertility
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21
Q

What is the treatment for Fibroids?

A

Hormonal (eg continuous OCP, prog, continuous GnRH agonists)

Hysterectomy

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22
Q

What are 2 non-endocrine causes of female infertility?

A

Fibroids, Endometriosis

23
Q

Describe the HPG axis in regards to fertility

A

Kisspeptin neurons secrete Kisspeptin that activate kisspeptin receptors on GnRh neurons. GnRh neurons secrete GnRh in local circulation that arrive at Gonadotrophs in the anterior pituitary, which are activated to produce LH &FSH, these pass to the gonads stimulating testosterone/oestrogen secretion. Negative feedback loop.

24
Q

What would happen to LH/FSH/T in hyperprolactinaemia?

A

All down

25
Q

What pattern would you see for LH/FSH/T in primary testicular failure e.g. Klinefelters Syndrome?

A

LH/FSH increase

T down

26
Q

What can shut down your hypothalamus?

A

Congenital Hypogonadotrophic Hypogonadism
-Anosmic (Kallmann Syndrome) or NormosmicAcquired Hypogonadotrophic Hypogonadism
-Low BMI, XS exercise, Stress
Hyperprolactinaemia

27
Q

What are Pituitary causes for infertility?

A

Hypopituitarism

-Tumour, Infiltration, Apoplexy, Surgery, Radiation

28
Q

What are gonadic causes for infertility?

A

Congenital Primary Hypogonadism
- Klinefelters 47XXY
Acquired Primary Hypogonadism
- Cryptorchidism, Trauma, Chemo, Radiation

29
Q

What are some other causes of male infertility?

A

Androgen receptor deficiency - Rare

Hyper/Hypothyroidism reduction in bioavailable testosterone.

30
Q

What is Kallmann’s syndrome?

A

Failure of migration of GnRH neurons.
Hypogonadotrophic
Hypogonadism
Anosmia (loss/change in smell)

31
Q

What are the reproductive features of Kallmann’s syndrome?

A 
Cryptorchidism
Failure of puberty
-Lack of testicle dvlpt
-Micropenis
-Primary amenorrhoea
Infertility
32
Q

How does Hyperprolactinaemia inhibit kisspeptin neurons?

A

Axis flooded with Prolactin, Binds to prolactin receptors on Kisspeptin neurons, inhibit kisspeptin release.

33
Q

What is the presentation of hyperprolactinaemia?

A

Female - Oligo/Amenorrhea
Male - Low libido
Infertility, Osteoporosis

34
Q

What is the treatment for Hyperprolactinaemia

A 
Dopamine agonist (cabergolin)
Surgery
35
Q

Describe Klinefelter’s syndrome?

A

47XXY
Hypergonadotrophic
Hypogonadism
Infertility, micropenis, breast development, narrow shoulders, reduced chest hair, Mildly impaired IQ, Wide hips, Low bone density

36
Q

How do you assess a male patient for infertility in the clinic?

A

including duration, previous children, pubertal milestones, associated symptoms (eg. T deficiency, PRL symptoms, CHH features), medical & surgical history, family history, social history, medications/drugs

37
Q

What are the examinations for male infertility?

A

including BMI, sexual characteristics, testicular volume, epididymal hardness, presence of vas deferens, other endocrine signs, syndromic features, anosmia

38
Q

What investigationsh should be carried out to assess male infertility?

A

Blood Tests; LH, FSH, PRL, Morning Fasting Testosterone
Sex Hormone Binding Globulin (SHBG), Albumin, Iron studies, Also Pituitary/Thyroid profile, Karyotyping.

Semen analysis; 1.5ml volume, 15million/ml conc, 40% motility.

Microbiology; Urine test, Chlamydia swab.

Imaging; Scrotal US/Doppler (for varicocoele/obstruction, testicular volume), Pituitary MRI ( if low FSH/LH or high PRL).

39
Q

What are the lifestyle treatments for male infertility?

A

Reduce BMI
Smoking cessation
Alcohol reduction/ cessation

40
Q

What are the specific treatments for male infertility?

A

Dopamine agonist for hyperPRL

Gonadotrophin treatment for fertility (will also increase testosterone)

Testosterone
(for symptoms if no fertility required – as this requires gonadotrophins)

Surgery
(eg. Micro Testicular Sperm Extraction (micro TESE))

41
Q

What is premature ovarian insufficiency?

A

same symptoms as menopause, 20% chance of conception. Diagnosis is High FSH>25iU/L (x2 at least 4 weeks apart)

42
Q

What are the causes of Premature ovarian insuffieciency?

A

Autoimmune
Genetic - Fragile X syndrome, turners syndrome.
Cancer therapy

43
Q

What happens in Polycystic Ovarian Syndrome?

A

Most common endocrine disorder in women 5-15%

Most common cause of female infertility

44
Q

How do you diagnose Polycystic ovarian syndrome?

A

Rotterdam PCOS Diagnostic criteria 2/3

45
Q

What are the criteria in the Rotterdam PCOS Diagnostic criteria?

A

Oligo or Anovulation
Clinical +/- Biochemical Hyperandrogenism
Polycystic Ovaries

46
Q

What is the criteria for Oligo or Annovulation?

A

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

47
Q

What is the criteria for Clinical +/- Biochemical Hyperandrogenism?

A

CLINICAL
Acne, hirsutism (Ferriman-Gallwey score), alopecia (Ludwig score)

BIOCHEMICAL
Raised androgens (eg Testosterone
48
Q

What is the criteria for Polycystic Ovaries?

A

≥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

49
Q

What is the treatment for Polycystic Ovarian syndrome?

A

Depends on what you are treating;
Irregular menses/amenorrhea - Oral Contraceptive, Metformin
Insulin resistance - Metformin, Diet & Lifestyle
Hirsutism - Anti-androgens, Creams, waxing, laser
Endometrial cancer risk - Progesterone courses

50
Q

What are the symptoms for turners syndrome (45X0)?

A

Short stature, low hairline, shield chest, wide spaced nipples, short 4th metacarpal, webbed neck, coarctation of the aorta, poor breast development, amenorrhea, underdeveloped reproductive tract,
1;2500 live births

51
Q

What extras would you ask about in a female history taking?

A

Beastfeeding, Menstrual history

52
Q

What extra examination would you carry out for a female?

A

hyperandrogenism signs, pelvic examination.

53
Q

What extra blood tests would you do in a female, if you are examining fertility?

A

Oestradiol, Foll phase OHP (rare problem causing hyerandrogenism), Mid luteal Prog(helps us tell if there has been ovulation.

54
Q

What does it indicate if progesterone rises in the luteal phase?

A

Acorpus luteum has formed, egg has come out of a follicle to form the corpus luteum, ovulation has taken place.

BRS Phase 1b (80 decks)

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