Infertility Flashcards
What is infertility?
‘A disease of the reproductive system defined by the failure to achieve a clinical pregnancy after ≥12 months of regular unprotected sexual intercourse.’
“regular”= every 2-3 days
What are the 2 types of infertility?
Primary= not had a live birth previously
Secondary= Have had a live birth >12 months previously
What impact can infertility have on a couple?
Psychological distress to Couple
- No biological child
- Impact on couples wellbeing
- Impact on larger family
- Investigations
- Treatments (often fail)
What impact can infertility have on society?
Cost to Society
- Less births
- Less tax income
- Investigation costs
- Treatment costs
What are the 3 categories of the causes of Male infertility?
- pre-testicular
- testicular
- post-testicular
What are some examples of pretesticular causes of male infertility?
Congenital & Acquired Endocrinopathies
- Klinefelters 47XXY (extra chromosome)
- HPG (issues in the reproductive axis), T (testosterone), PRL issues (progesterone)
What are some examples of testicular causes of infertility in males?
(Congenital) Cryptorchidism
Infection (STDs)
Immunological (Antisperm Abs)
Vascular (Varicocoele- abnormally dilated veins in the scrotum)
Trauma/Surgery
Toxins (Chemo/DXT/Drugs/Smoking)
What are some of the post-testicular causes of male infertility?
Congenital (absence of vas deferens in CF- tube that carries sperm out of the testes)
Obstructive Azoospermia (sperm is obstructed)
Erectile Dysfunction: Retrograde Ejaculation, Mechanical Impairment, Psychological
Iatrogenic (Vasectomy)
What is Cryptorchidism?
- Undescended testes- instead of descending through the inguinal canal, 90% remains in the canal
- It is an example of acquired primary hypogonadism (hypergonadotrophic- more LH and FSH seen attempting to compensate)
(hypogonadism- less testosterone- issue with the gland/organ itself)
What causes of infertility in females relate to issues in the ovaries?
OVARIAN CAUSES (40%)
-Anovulation (Edo- when an egg (ovum) doesn’t release from your ovary during your menstrual cycle)
-Corpus luteum insufficiency (failure of embryo to advance due to low progesterone)
What causes of infertility in females relate to issues in the fallopian tube?
Tubal Causes (30%)
Tubopathy due:
-Infection
-Endometriosis (tissue similar to the lining of the womb grows in other places, such as the ovaries and fallopian tubes.)
-Trauma
What causes of infertility in females relate to issues in the uterus?
Uterine Causes (10%)
Unfavourable endometrium (embryo cannot attach) due:
-Congenital malformations
-Infection/Inflammation/Scarring (adhesions)
-Fibroids
What causes of infertility in females relate to issues in the cervix?
Cervical Causes (5%)
Ineffective sperm penetration due:
-Infection/Inflammation
-Immunological (antisperm Ab)
What is Endometriosis?
Presence of functioning endometrial tissue outside the uterus (found on outer uterine surface, fallopian tube, ovaries, cul de sac area, etc)
-5% of women
-Responds to oestrogen
Symtpoms:
* ↑ Menstrual pain
* Menstrual irregularities
* Deep dyspareunia (pain during sex)
* Infertility
What are fibroids?
“Benign tumours of the myometrium found all over the female sex organ”
-1-20% of pre-menopausal women (increases w age)
-Responds to oestrogen
Symptoms:
* Usually asymptomatic
* ↑ Menstrual pain
* Menstrual irregularities
* Deep dyspareunia (pain during sex)
* Infertility
(picked up on ultrasound quite quickly)
What are examples of Secondary hypogonadism causing male infertility? What is detected to confirm secondary hypogonadism?
- Congenital Hypogonadotrophic Hypogonadism
e.g. Anosmic (Kallmann Syndrome) or Normosmic - Acquired Hypogonadotrophic Hypogonadism
-Low BMI, XS exercise, Stress - Hyperprolactinaemia
(Hypogonadotrophic- low LH/FSH= issues with the hypothalamic-pituitary gonadal axis, low GnRH but not measurable)
(Hypogonadism- low testosterone=due to low GnRH/LH/FSH)
- Hypopituitarism
e.g. Tumour, Infiltration, Apoplexy, Surgery, Radiation
(Hypogonadotrophic- low LH/FSH= issues with the hypothalamic-pituitary gonadal axis)
(Hypogonadism- low testosterone= due to low LH/FSH)
What are examples of Primary hypogonadism causing male infertility? What is detected to confirm primary hypogonadism?
- Congenital Primary Hypogonadism
e.g. Klinefelters (47XXY) - Acquired Primary Hypogonadism
e.g. Cryptorchidism, Trauma, Chemo, Radiation
(hypergonadotrophic- High FSH and High LH- attempting to restore testosterone= axis still working)
(Hypogonadism- Low testosterone- issue with the testes/ gland/ organ itself)
What is Kallmann Syndrome?
“Failure of migration of GnRH neurons with olfactory fibres”
Results in anosmia (failure to smell)
Failure of puberty
Infertility
- Secondary hypogonadism
(Hypogonadotrophic- low LH/FSH= issues with the hypothalamic-pituitary gonadal axis, low GnRH but not measurable)
(Hypogonadism- low testosterone= due to low GnRH/FSH/LH)
What is hyperprolactinaemia? How does this cause infertility?
“too much prolactin”
Binds to prolactin receptors on kisspeptin neurons in hypothalamus
Inhibits kisspeptin release (role of kisspeptin: stimulates GnRH/LH/FSH release)
Treated with dopamine agonist “cabergoline” (dopamine inhibits prolactin), surgery, DXT
- Secondary hypogonadism
(Hypogonadotrophic- low LH/FSH= issues with the hypothalamic-pituitary gonadal axis, low GnRH but not measurable)
(Hypogonadism- low testosterone= due to low GnRH/FSH/LH)
What is Klinefelter Syndrome?
“When males are born with an extra X chromosome”(47XXY)
Symptoms:
Tall stature
↓ Facial hair
Breast development
Female-type pubic hair pattern
Small penis & testes
Infertility
Mildly impaired IQ
Narrow shoulders
Reduced chest hair
Wide hips
Low bone density
-Primary hypogonadism
(hypergonadotrophic- High FSH and High LH- attempting to restore testosterone= axis still working)
(Hypogonadism- Low testosterone- issue with the testes/ gland/ organ itself)
What are the key components of the history you need to diagnose male infertility?
Key History:
Duration
previous children (unlikely to be a congenital cause) Pubertal milestones
Associated symptoms (eg. T deficiency, PRL symptoms, CHH features)
Medications/drugs
What are the key examinations you would undertake when diagnosing male infertility?
Key Examination:
BMI
sexual characteristics
testicular volume
anosmia (test their sense of smell)
What are the key investigations you would carry out to diagnose male infertility?
- Blood Tests:
LH, FSH, PRL
Morning Fasting Testosterone (carbohydrates can suppress testosterone)
Karyotyping - Imaging:
Scrotal US/Doppler
(for varicocoele/obstruction, testicular volume)
MRI Pituitary
(if low LH/FSH or high PRL) - Semen Analysis
NORMAL:
Volume of semen=1.5ml
Sperm conc= 15 million/ml
(Azospermia = No sperm
Oligospermia = Reduced sperm)
How would you treat male infertlity?
FIRST GENERAL LIFESTYLE:
1. Optimise BMI
2. Smoking cessation
3. Alcohol reduction/cessation
SPECIFIC TREATMENT:
1. Dopamine agonist for hyperPRL
2. Gonadotrophin treatment for fertility (will also increase testosterone)
3. Testosterone
(for symptoms if no fertility required – as this requires gonadotrophins)
4. Surgery
(eg. Micro Testicular Sperm Extraction (micro TESE))
What is Premature Ovarian Insufficiency?
“Woman’s ovaries stop making normal levels of certain hormones- esp oestrogen”
Causes: autoimmune, genetic (e.g. Turner’s syndrome), cancer therapy (radio/ chemotherapy) CAN BE CONGENITAL OR AQUIRED
Symptoms
* (same as menopause)
* Conception happens in 20% of cases
- Primary hypogonadism
(Hypergonadotrophic= High FSH and High LH- attempting to restore estradiol)
(Hypogonadism= Low estradiol- issue with the ovaries/ organ/ gland itself)
What is Anorexia Nervosa-Induced Amenorrhea?
“Body can’t access nutrition, therefore, hormone levels drop (oestrdial)”
symtpoms:
* period stops
-Secondary hypogonadism
(Hypogonadotrophic- low LH/FSH= issues with the hypothalamic-pituitary gonadal axis, low GnRH but not measurable)
(Hypogonadism- low oestradiol= due to low FSH/LH/GnRH)
What are examples of Secondary hypogonadism causing female infertility? What is detected to confirm secondary hypogonadism?
1.Congenital Hypogonadotrophic Hypogonadism
e.g. Anosmic (Kallmann Syndrome) or Normosmic
2. Acquired Hypogonadotrophic Hypogonadism
-Low BMI, XS exercise, Stress, Anorexia nervosa- induced Amenorrhea
3. Hyperprolactinaemia
(Hypogonadotrophic- low LH/FSH= issues with the hypothalamic-pituitary gonadal axis, low GnRH but not measurable)
(Hypogonadism- low oestradiol= due to low GnRH/LH/FSH)
- Hypopituitarism
e.g. Tumour, Infiltration, Apoplexy, Surgery, Radiation
(Hypogonadotrophic- low LH/FSH= issues with the hypothalamic-pituitary gonadal axis)
(Hypogonadism- low oestradiol= due to low LH/FSH)
What are examples of Primary hypogonadism causing female infertility? What is detected to confirm primary hypogonadism?
- Congenital Primary Hypogonadism
e.g. Turners (45X0)
e.g. Premature Ovarian Insufficiency (POI) - Acquired Primary Hypogonadism
e.g. Premature Ovarian Insufficiency (POI)
e.g. Surgery, Trauma, Chemo, Radiation
3.Polycystic Ovarian Syndrome (PCOS)
-Primary hypogonadism
(hypergonadotrophic- High FSH and High LH- attempting to restore oestradiol= axis still working)
(Hypogonadism- Low oestradiol- issue with the ovaries/ gland/ organ itself)
What is polycystic Ovarian Syndrome?
“condition that affects how a woman’s ovaries work”
Symptoms:
* Irregular/ no periods
* Infertility
* Hirsutism
* Weight gain
* Thinning/ loss of hair
* Oily skin/ acne
-Primary hypogonadism
(hypergonadotrophic- High FSH:LH- attempting to restore oestradiol= axis still working)
normal oestradiol or hypogonadism (low oestradiol)
What are some complications of Polycystic Ovarian syndrome and how would you treat each complication?
- Irregular menses/ amenorrhoea (metformin, oral contraceptive pill, ovulation induction e.g. IVF)
- Insulin resistance & Impaired glucose homestasis like T2DM and gestational DM (metformin, diet & lifestyle changes)
- Hirsutism (Anti-androgens like spironolactone, creams, waxing, laser
- Increased endometrial cancer (progesterone courses)
What are the key components of the history you need to diagnose the cause of female infertility?
Key History:
Duration
Previous children
Pubertal milestones
Menstrual History
Medications/drugs
What are the key examinations you would conduct to diagnose the cause of female infertility?
Key Examination:
BMI
sexual characteristics
hyperandrogenism signs
anosmia
What are the key investigations you would conduct to diagnose the cause of female infertility?
- Blood Tests:
LH, FSH, PRL
Oestradiol, Androgens
Mid- Luteal Prog
Karyotyping - Pregnancy Test
(urine or serum HCG) - Imaging:
US (transvaginal)
Hysterosalpingogram
MRI Pituitary
(if low LH/FSH or high PRL)
What is Turners Syndrome?
“female is born with only 1 normal X sex chromosome, rather than the usual 2”
Symptoms:
* Short stature
* Low hairline
* Shield chest
* Wide-spaced nipples
* Short 4th metacarpal
* Small fingernails
* Brown nevi
* Amenorrhea
* Underdeveloped reproductive tract
* Elbow deformity
* Poor breast development
* Coarctation of aorta
* Webbed neck
* Characteristic facies
-Primary hypogonadism
(Hypergonadotrophic= High FSH and High LH- attempting to restore estradiol)
(Hypogonadism= Low estradiol- issue with the ovaries/ organ/ gland itself)
