Presence of functioning endometrial tissue outside the uterus - 5% of women - Responds to oestrogen

Benign tumours of the myometrium - 1-20% of pre-menopausal women (increases w age) - Responds to oestrogen

Infertility Flashcards by Yipei Sun

Infertility

A disease of the reproductive system defined by the failure to achieve a clinical pregnancy after ≥12 months of regular unprotected sexual intercourse

Primary - no previous live births
Secondary - live birth more than a year prior

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Most common cause of infertility

30% female
30% male
30% both
10% unknown

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Infertility causes pre-testicular

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

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Infertility causes testicular

(Congenital)

Cryptorchidism

Infection
STDs

Immunological
Antisperm Abs

Vascular
Varicocoele

Trauma/Surgery

Toxins
Chemo/DXT/Drugs/Smoking

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Infertility causes post-testicular

Congenital
Absence of vas deferens in CF

Obstructive Azoospermia

Erectile Dysfunction
Retrograde Ejaculation Mechanical
Impairment Psychological

Iatrogenic
Vasectomy

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Cryptorchidism

Undescended testis (in inguinal canal)

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Infertility causes pelvic

Endometriosis
Adhesions

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Infertility causes tubal

Tubopathy due:

Infection
Endometriosis
Trauma

30%

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Infertility causes ovarian

Anovulation (Endo)
Corpus luteum insufficiency

40%

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Infertility causes uterine

Chronic endometritis (TB)
Fibroid
Adhesions (Synechiae)
Congenital malformation

10%

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Infertility causes cervical

Ineffective sperm penetration due:

Chronic cervicitis
Immunological (antisperm Ab)

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Endometriosis

Presence of functioning endometrial tissue outside the uterus

5% of women
Responds to oestrogen

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Endometriosis symptoms

↑ Menstrual pain
Menstrual irregularities
Deep dyspareunia
Infertility

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Endometriosis treatments

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

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Fibroids

Benign tumours of the myometrium

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

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Fibroids symptoms

Usually asymptomatic
↑ Menstrual pain
Menstrual irregularities
Deep dyspareunia
Infertility

Fibroids treatment

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

Hysterectomy

Male infertility in hypothalamus

Congenital Hypogonadotrophic Hypogonadism
-Anosmic (Kallmann Syndrome) or Normosmic

Acquired Hypogonadotrophic Hypogonadism
-Low BMI, XS exercise, Stress

Hyperprolactinaemia

Decreased GnRH, LH, FSH, T

Male infertility in anterior pituitary

Hypopituitarism
-Tumour, Infiltration, Apoplexy, Surgery, Radiation

Decreased LH, FSH, T

Male infertility in gonads

Congenital Primary Hypogonadism
-Klinefelters (47XXY)

Acquired Primary Hypogonadism
-Cryptorchidism, Trauma, Chemo, Radiation

Increased LH and FSH, decreased T

Kallmann Syndrome

Failure of migration of GnRH neurons with olfactory fibres

Anosmia 
Cryptorchidism
Failure of puberty
-Lack of testicle dvlpt
-Micropenis
-Primary amenorrhoea
Infertility

Klinefelters Syndrome

Tall
Decreased facial hair 
Breast development 
Mildly impaired IQ
Narrow shoulder 
Wide hips

Male Infertility: Initial History, Examination & Investigation

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

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

Investigation: semen analysis, blood test, urine test, scrotal ultrasound , MRI pituitary

Male Infertility: Treatment

Optimise BMI
Smoking cessation
Alcohol reduction/cessation

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))

Menarche

Menstrual Cycles - 28-day cycle (24-35 days). - ±2 days each month. Primary Amenorrhoea - Later than 16yrs is regarded as abnormal. Secondary Amenorrhoea - Common for Periods to be irregular / anovulatory for first 18months. - Periods start but then stop for at at least 3-6 months Amenorrhoea - Absence of Periods - No periods for at least 3-6 months. - or up to 3 periods per year. Oligo-menorrhoea - Few Periods - Irregular or Infrequent periods >35day cycles - or 4-9 cycles per year.

Premature Ovarian Insufficiency

Same Symptoms as per Menopause Previously called ‘Premature Ovarian Failure’ POF Conception can happen in 20%. Diagnosis High FSH >25 iU/L (x2 at least 4wks apart) Causes Autoimmune Genetic eg Fragile X Syndrome / Turner’s Syndrome Cancer therapy Radio- / Chemo-therapy in the past

Female infertility in hypothalamus

Congenital Hypogonadotrophic Hypogonadism -Anosmic (Kallmann Syndrome) or Normosmic Acquired Hypogonadotrophic Hypogonadism -Low BMI, XS exercise, Stress Hyperprolactinaemia Decreased GnRH, LH, FSH, estrogen

Female infertility in anterior pituitary

Hypopituitarism -Tumour, Infilatration, Apoplexy, Surgery, Radiation Decreased LH, FSH, estrogen

Female infertility in gonads

Polycystic Ovarian Syndrome (PCOS) Acquired Primary Hypogonadism - Premature Ovarian Insufficiency (POI) - Surgery, Trauma, Chemo, Radiation Congenital Primary Hypogonadism - Turners (45X0) - Premature Ovarian Insufficiency (POI) Increase LH:FSH, LH, FSH Decreased estrogen

Polycystic Ovarian Syndrome: Diagnosis

Rotterdam PCOS Diagnostic Criteria (2 out of 3) Oligo or Anovulation Clinical +/- Biochemical Hyperandrogenism Polycystic Ovaries (US) 1 and 2 worst metabolic risk combo

Polycystic Ovarian Syndrome: Treatments

``` Infertility - Clomiphene, IVF Irregular menses - oral contraceptive pill, metformin Insulin resistance - metformin, diet Hirsutism - wax, laser, anti androgens Endometrial cancer risk - progesterone ```

Turners Syndrome (45 X0)

``` Short stature Low hairline Webbed neck Shield chest Elbow deformity Coarctation of aorta Poor brest development ```

Female Infertility: Initial History, Examination & Investigation

History: including duration, previous children, pubertal milestones, breastfeeding?, Menstrual History: oligomenorrhoea or 1/20 amenorrhoea, associated symptoms (eg. E deficiency, PRL symptoms, CHH features), medical & surgical history, family history, social history, medications/drugs Examination: including BMI, sexual characteristics, hyperandrogenism signs, pelvic examination, other endocrine signs, syndromic features, anosmia Investigation: Blood (LH, FSH, PRL), pregnancy test, urine test, ultrasound (transvaginal), MRI pituitary