infertility Flashcards
What is infertility defined as?
Disease of reproductive system with inability to have clinical pregnancy after at least 12 months of regular sex (every 2-3 days)
What is primary and secondary infertility?
Primary - no live births. Secondary - live birth more than 12 months ago
What are the different types of infertility?
Female factor, male factor, combination.
What are the costs of infertility to society and the couple?
Psychoglocial distress and less tax revenue as less children
How does the HPG axis work?
Kisspeptin neurones bind on kisspeptin receptors on GnRH neurones, GnRH travels to anterior pituitary where gonadotrophs make LH and FSH and go into systemic circulation to ovaries/testes to make oestrogen progesterone testosterone etc
How is male inferitlity causes divided?
Pre-testicular, testicular, post-testicular
What are causes of pre-testicular male infertility?
Klinefelters syndrome XXY, Y chromosome deletion
What are causes of testicular infertity?
Radiation/infection/trauma, cryptorchidism, varicocele (enlargement of testicular veins) , smoking drugs surgery
What are causes of post-testicular infertility?
Erectile dysfunction - psychological, high PRL, retrograde ejaculation, mechanical, absence of vas deferens, obstructive azoospermia (absence of spermatozoa in ejaculate)
What is cryptorchidism?
Undescended testes through inguinal canal (remain in inguinal canal
What is klinefelter syndrome? What are the symptoms? blood test?
XXY - have extra X chromosome, present with infertility, low testosterone high LH/FSH, female features (breast developed, wide hips), small penis, female pubic hair pattern, tall stature, decreased facial hair, narrow shoulders, reduced chest hair.
-hypergonadotrophic hypogonadism (low T, high LH/FSH)
In endocrine male infertility, where can the defects occurs?
Hypothalamus, pituitary, gonads
What defects in hypothalamus would cause infertility? What would blood tests show?
Congenital hypogonadotrophic hypogonadism - low GnRH - low LH/FSH - low testosteorne (eg. Kallman’s syndrome (anosmic) or normosmic). 2. aquired hypogonadotrophic hypogonadism - low BMI, stress, excess exercise
What defects in pituitary would cause inferrility + blood test?
Hyperprolactinaemia, tumours, apoplexy, radiation
What defect in gonads causes infertility + blood test?
Congenital primary hypogonadism - klinefelters XXY - low T high LH/FSH. Acquired primary hypogonadism - trauma, cancer, radiation, cryptorochidism
What other endocrine causes of male infertility?
High prolactin, hyperthyroidism/hypo (decreases bioavailable testosterone), androgen receptor deficiency
What history should be taken for male infertility?
Age of puberty, symptoms, previous children, duration surgical history, family history, medical history, drugs
What examination should be performed for male inferitlity?
BMI, sexual characteristics, epidydimis hardness, testicular volume, vas deferens prescence, anosmia, endocrine signs
What are the main investigations sthat should be done for male infertility? What blood tests should be done? What microbiological investigations? What imaging?
Sperm analysis - motility 40% etc. bloods –> morning fasting testosterone, LH, PRL, T sex hormone binding globulin SHBG, abulim/iron, pituitary/.thyroid, karyotyping
What treatments for male inferitility?
For fertility - gonadotrophin inections. For symptoms - testosterone. Surgery. Dopamine agonists (cabergoline) for hyperprolactinaemia
How does hyperprolactinaemia cause infertility and how does it present? Treatment?
High prolactin binds to prolactin receptoprs on kisspeptin neurones inhibiting kisspeptin release and therefore downward GnRH hormones and pulsatility turned off.
What are sex chromosome disorders in men and women?
Klinefelters XXY men, fragile X syndrome (both), turners syndrome (X0), triple x syndrome XXX
What are causes of female infertility divided in?
pelvic, tubal, ovarian, uterine, cervical
What are pelvic causes of female infertiltiy?
Endometriosis, adhesions
What are tubal causes of infertility?
Tubopathy due to infection, endometriosis, , trauma
What are ovarian causes ?
Endometriosis (anovulation), corpus luteum insufficinecy
What are uterine causes of infertility?
Fibroids, adhesions, unfavouralbe endometrium due to chronic endometritis
What are cervical causes of infertility?
Chronic cervicitis, anti-sperm antibodies
What is endometriosis? Symptoms? Treatments?
Growth of endometrial tissue in places other than the uterus. Responds to oestrogen and bleeds same way as endometrial tissue. Causes menstrual pain, irregularities deep dyspareunia, infertility. Treatments - birth control OCP, laparoscopic ablation, hysterectomy, salpingo-ooperectomy
What are fibroids? Symptoms? Treatments?
Benign tumorus of the myometrium. Risk increases with age. Usually asymptomatic but respopnd to oestrogen. Can cause menstrual pain & irregularities & deep dyspareunia. Treated with OCP, progesterone, continuous GnRH, hysterectomy
What is menarche usually? Primary amenorrhea? Secondary? A-menorrhea? Olig-menorrhea?
28 days +/-2 . Primary ammenorrhea no period before 16 yrs. Seoncdary used to have period but stopped for at least 3-6 months. Amenorrhea - no period for at least 3-6 months or less than 3 a year. Oligomennorhea - less periods
What is early menopause (premature ovarian insuffiency POI)? Symptoms? How is it diagnosed? Wat are causes?
Same symptoms as normal menopause - but earlier. Diangosis is high FSH > 25 on 2 occatsions at least 4 weeks apart. Causes - autoimmune, fragile X, turners, cancer (radiotherapy, chemo) high FSH, low oestrgoen
How is PCOS diagnosed? Which is the worst metabolic combination and why?
Rotterdam PCOS criteria - need 2/3 of the following - polycystic morhpology on ultrasound, hyperandrogenism clicnial +/- biochemical (clinical - hirsutism, acne, alopecia), oligo or anovulation. Worst metbaolic is hyperandrogenism + anovulation because it slows metabolism.
What is treatment for each problem of PCOS?
nfertility - IVF, clopmihene, letrozole. Insulin resistance liofestyle change + metformin. Hyperandrogenism - spironolactone (anti androgen) + creams/waxing. Periods - OCP. Progesterone courses for increased endometrial cancer risk
What is turner’s syndrome? Symptoms? Blood tests?
X0 - loss of one X chrnomosome. Short stature, shield chest, wide nipples, amenorrhea, elbow deformitiy, webbed neck, poor breast development, coarctation of aorta, low hairline, short 4th metacarpal, small fingernails, brown nevi, underdeveloped reproductive tract (low E but high LH/FSH) - hypergonadotrophic hypergonadism
What history should be taken for women? What is additional to men?
Menstrual hisotry, previous pregnancies, dymptoms, breastfeeding
Why foll-phase 17-OHP blood test?
congenital adrenal hyperplasia
Why mid-luteal progesterone?
Successful ovulation if detected
Main investigations? What imaging for female infertility?
Bloods, oestradiol, androgens, foll phase 17-OHP, mid-luteal progesterone as well. Additional pregnancy test. Imaging transvaginal ultrasound, hysterosalpingogram, MRI pituitary
what is kallmans syndrome? blood tests? features?
failure of GnRH neurones to migrate with olfactory fibres via olfactory placode into hypothalamus during embyrological development
- low GnRH, low LH/FSH, low T –> hypogonadrotrophic hypogonadism
- anosmia, cryptorchidism, failure of puberty, lack of testicle development, micropenis, primary amenorrhea, infertility
