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BRS Flashcards (Y2) > Infertility > Flashcards

Infertility Flashcards

1
Q

What is infertility?

A

‘A disease of the reproductive system defined by the failure to achieve a clinical pregnancy after ≥12 months of regular unprotected sexual intercourse.’
WHO 2009
Regular intercourse = every 2-3 days

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2
Q

What is the difference between primary and secondary infertility?

A

Primary: Not had a live birth previously
Secondary: Not had a live birth >12 months previously

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3
Q

How common is infertility?

A

Affects 1 in 7 couples (= 14% of couples)
But ~ half of these will then conceive in the next 12 months (ie at 24months ~ 7% of couples)

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4
Q

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

A

Male factor - 30%
Female factor - 30%
Male & female factor - 30%
Unknown - 10%

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5
Q

What are some psychological impacts of infertility on couples?

A

No biological child
Impact on couples wellbeing
Impact on larger family
Investigations
Treatments (often fail)

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6
Q

What are some impacts of infertility on society?

A

Less births
Less tax income
Investigation costs
Treatment costs

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7
Q

What are some pre-testicular causes of infertility in males?

A

Congenital & Acquired Endocrinopathies:
- Klinefelters 47XXY
- HPG, T, PRL issues

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8
Q

What are some testicular causes of infertility in males?

A

Congenital
Cryptorchidism
Infection: STDs
Immunological: antisperm Abs
Vascular: varicocoele
Trauma/surgery
Toxins: chemo/DXR/drugs/smoking

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9
Q

What are some post-testicular causes of infertility in males?

A

Congenital: absence of vas deferens in cystic fibrosis
Obstruction azoospermia
Erectile dysfunction: retrograde ejaculation, mechanical impairment and psychological
Iatrogenic: vasectomy

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10
Q

What happens in cryptorchidism?

A

Undescended testis - 90% in inguinal canal

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11
Q

What are the pelvic causes of female infertility?

A

Endometriosis
Adhesions

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12
Q

What are the tubal causes of female infertility?

A

Infection
Endometriosis
Trauma

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13
Q

What are the ovarian causes of female infertility?

A

Anovulation
Corpus luteum insufficiency

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14
Q

What are the uterine causes of female infertility?

A

Unfavourable endometrium due:
-Congenital malformations
-Infection/Inflammation/Scarring (adhesions)
- Fibroids

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15
Q

What are the cervical causes of female infertility?

A

Ineffective sperm penetration due:
- Infection/Inflammation
- Immunological (antisperm Ab)

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16
Q

What is endometriosis and how common is it?

A

Presence of functioning endometrial tissue outside the uterus
Occurs in 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 (painful intercourse)
Infertility

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18
Q

What are fibroids?

A

Benign tumours of the myometrium
Occur in 1-20% of pre-menopausal women (increases with age)
Respond to oestrogen

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19
Q

What are the symptoms of fibroids?

A

Usually asymptomatic
↑ Menstrual pain
Menstrual irregularities
Deep dyspareunia
Infertility

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20
Q

How would you describe GnRH and LH levels?

A

Pulsatile

21
Q

How would you describe sex steroid levels?

A

Follow a diurnal rhythm

22
Q

What would you expect to happen to LH, FSH and testosterone levels in hyperprolactinaemia?

A

Down, down, down
Hypogonadotrophic hypogonadism

23
Q

What would you expect to happen to LH, FSH and testosterone levels in Primary Testicular Failure?

A

LH/FSH- Up
Testosterone- Down
Hypergonadotrophic hypogonadism

24
Q

What are the causes of hypothalamic (low GnRH) hypogonadotrophic hypogonadism?

A

Congenital HH:
- Anosmic (Kallman Syndrome or Normosmic)
Acquired HH:
- Low BMI, excessive exercise, stress
Hyperprolactinaemia

25
Q

What are the pituitary causes of hypogonadotrophic hypogonadism?

A

Hypopituitarism:
- tumour
- infiltration
- apoplexy
- surgery
- radiation

26
Q

What are the causes of hypergonadotrophic hypogonadism in men?

A

Congenital primary hypogonadism:
- Klinefelters (47XXY)
Acquired primary hypogonadism:
- Cryptorchidism
- Trauma
- Chemo
- Radiation

27
Q

What is the pathophysiology of Kallmann Syndrome?

A

Failure of migration of GnRH neurons with olfactory fibres causing anosmia and hypogonadotrophic hypogonadism

28
Q

What are the reproductive features of Kallmann Syndrome?

A

Failure of puberty
Infertility

29
Q

How does hyperprolactinaemia cause hypogonadatrophic hypogonadism?

A

Prolactin binds to prolactin receptors on kisspeptin neurons in hypothalamus - inhibits kisspeptin release
Decreases downstream GnRH/LH/FSH/T/Oest

Causes:
- Oligo (>35d menses) or amenorrhoea (3-6m no menses)
- Low libido (and other hypogonadal symptoms)
- Infertility
- Osteoporosis

30
Q

What is the treatment of hyperprolactinaemia?

A

Dopamine agonist (Cabergoline)
Surgery/DXT

31
Q

What is Klinefelters Syndrome and what are the features?

A

XXY causing hypergonadotrophic hypogonadism

Features:
Tall stature
Reduced facial hair
Breast development
Female-type pubic pattern
Small penis and testes
Infertility
Mildly impaired IQ
Narrow shoulders
Reduced chest hair
Wide hips
Low bone density

32
Q

What must be considered when taking an initial history for male infertility?

A

Duration
Previous children
Pubertal milestones
Associated symptoms (testosterone deficiency, PRL symptoms, CHH features)
Medications/drugs

33
Q

What are some key examinations for male infertility?

A

BMI
Sexual characteristics
Testicular volume
Anosmia

34
Q

What are some key investigations for male infertility?

A

Semen analysis
Blood tests:
- LH, FSH, PRL
- Morning fasting testosterone
- Karyotyping
Imaging:
- Scrotal US/Doppler
- Pituitary MRI

35
Q

What are typical findings in semen analysis and what are the terms used to describe no/reduced sperm?

A

1.5 mL
15 million sperm /mL
40% motility

Azospermia - no sperm
Oligospermia - reduced sperm

36
Q

What are conservative treatments for male infertility?

A

Optimise BMI
Smoking cessation
Alcohol reduction/cessation

37
Q

What are the medical treatments for male infertility?

A

Dopamine agonist - hyperprolactinaemia
Gonadotrophin treatment for fertility (also increases testosterone)
Testosterone (no fertility required)
Surgery (e.g. Micro Testicular Sperm Extraction - micro TESE)

38
Q

What is Premature Ovarian Insufficiency?

A

Same symptoms as menopause (but at an earlier age)
Conception can happen in 20%
Diagnosis - high FSH >25 iU/L (x2 at least 4wks apart)

39
Q

What are the causes of Premature Ovarian Insufficiency?

A

Autoimmune
Genetic eg Turner’s Syndrome
Radio-/chemo-therapy in the past

40
Q

What are the causes of hypergonadotrophic hypogonadism in women?

A

Congenital Primary Hypogonadism
-Turners (45X0)
-Premature Ovarian Insufficiency (POI)

Acquired Primary Hypogonadism
-Premature Ovarian Insufficiency (POI)
-Surgery, Trauma, Chemo, Radiation

Polycystic Ovarian Syndrome

41
Q

Describe the epidemiology of PCOS

A

Affects 5-15% of women of reproductive age (frequent family history)
Most common endocrine disorder in women
Most common cause of infertility in women

42
Q

What makes up the Rotterdam PCOS Diagnostic Criteria and when is it used?

A

Used after other reproductive disorders have been excluded
Criteria (2 out of 3):
- Oligo/anovulation
- Clinical (acne, hirsutism, alopecia) +/- biochemical hyperandrogenism (raised androgens)
- Polycystic ovaries (ultrasound)

43
Q

What are the characteristics of PCOS?

A

Irregular menses/amenorrhea - infertility
Increased insulin resistance - T2DM/gestational DM
Hirsutism
Increased endometrial cancer risk (x2-6)

44
Q

What drugs are used in the treatment of PCOS?

A
45
Q

What is Turner’s Syndrome and what are the symptoms?

A

45 X0
Hypergonadotrophic hypogonadism

46
Q

What are the key points covered in an initial history of female infertility?

A

Duration
Previous children
Pubertal milestones
Menstrual history
Medication/drugs

47
Q

What key examinations are done for female infertility?

A

BMI
Sexual characteristics
Hyperandrogenism signs
Anosmia

48
Q

What key investigations are done for female infertility?

A

Blood tests:
- LH, FSH, PRL
- Oestradiol, androgens
- Mid-luteal Prog
- Karyotyping
Pregnancy Test (urine or serum HCG)
Imaging:
- Transvaginal US
- Hysterosalpingogram
- Pituitary MRI

BRS Flashcards (Y2) (79 decks)

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