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Endocrinology > 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.’
“regular”= every 2-3 days

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2
Q

What are the 2 types of infertility?

A

Primary= not had a live birth previously
Secondary= Have had a live birth >12 months previously

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3
Q

What impact can infertility have on a couple?

A

Psychological distress to Couple
- No biological child
- Impact on couples wellbeing
- Impact on larger family
- Investigations
- Treatments (often fail)

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4
Q

What impact can infertility have on society?

A

Cost to Society
- Less births
- Less tax income
- Investigation costs
- Treatment costs

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5
Q

What are the 3 categories of the causes of Male infertility?

A
  1. pre-testicular
  2. testicular
  3. post-testicular
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6
Q

What are some examples of pretesticular causes of male infertility?

A

Congenital & Acquired Endocrinopathies
- Klinefelters 47XXY (extra chromosome)
- HPG (issues in the reproductive axis), T (testosterone), PRL issues (progesterone)

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7
Q

What are some examples of testicular causes of infertility in males?

A

(Congenital) Cryptorchidism
Infection (STDs)
Immunological (Antisperm Abs)
Vascular (Varicocoele- abnormally dilated veins in the scrotum)
Trauma/Surgery
Toxins (Chemo/DXT/Drugs/Smoking)

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8
Q

What are some of the post-testicular causes of male infertility?

A

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)

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9
Q

What is Cryptorchidism?

A
  • 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)
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10
Q

What causes of infertility in females relate to issues in the ovaries?

A

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)

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11
Q

What causes of infertility in females relate to issues in the fallopian tube?

A

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

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12
Q

What causes of infertility in females relate to issues in the uterus?

A

Uterine Causes (10%)
Unfavourable endometrium (embryo cannot attach) due:
-Congenital malformations
-Infection/Inflammation/Scarring (adhesions)
-Fibroids

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13
Q

What causes of infertility in females relate to issues in the cervix?

A

Cervical Causes (5%)
Ineffective sperm penetration due:
-Infection/Inflammation
-Immunological (antisperm Ab)

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14
Q

What is Endometriosis?

A

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

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15
Q

What are fibroids?

A

“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)

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16
Q

What are examples of Secondary hypogonadism causing male infertility? What is detected to confirm secondary hypogonadism?

A
  1. Congenital Hypogonadotrophic Hypogonadism
    e.g. Anosmic (Kallmann Syndrome) or Normosmic
  2. Acquired Hypogonadotrophic Hypogonadism
    -Low BMI, XS exercise, Stress
  3. 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)

  1. 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)
17
Q

What are examples of Primary hypogonadism causing male infertility? What is detected to confirm primary hypogonadism?

A
  1. Congenital Primary Hypogonadism
    e.g. Klinefelters (47XXY)
  2. 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)
18
Q

What is Kallmann Syndrome?

A

“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)

19
Q

What is hyperprolactinaemia? How does this cause infertility?

A

“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)

20
Q

What is Klinefelter Syndrome?

A

“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)

21
Q

What are the key components of the history you need to diagnose male infertility?

A

Key History:
Duration
previous children (unlikely to be a congenital cause) Pubertal milestones
Associated symptoms (eg. T deficiency, PRL symptoms, CHH features)
Medications/drugs

22
Q

What are the key examinations you would undertake when diagnosing male infertility?

A

Key Examination:
BMI
sexual characteristics
testicular volume
anosmia (test their sense of smell)

23
Q

What are the key investigations you would carry out to diagnose male infertility?

A
  1. Blood Tests:
    LH, FSH, PRL
    Morning Fasting Testosterone (carbohydrates can suppress testosterone)
    Karyotyping
  2. Imaging:
    Scrotal US/Doppler
    (for varicocoele/obstruction, testicular volume)
    MRI Pituitary
    (if low LH/FSH or high PRL)
  3. Semen Analysis
    NORMAL:
    Volume of semen=1.5ml
    Sperm conc= 15 million/ml
    (Azospermia = No sperm
    Oligospermia = Reduced sperm)
24
Q

How would you treat male infertlity?

A

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))

25
Q

What is Premature Ovarian Insufficiency?

A

“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)

26
Q

What is Anorexia Nervosa-Induced Amenorrhea?

A

“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)

27
Q

What are examples of Secondary hypogonadism causing female infertility? What is detected to confirm secondary hypogonadism?

A

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)

  1. 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)

28
Q

What are examples of Primary hypogonadism causing female infertility? What is detected to confirm primary hypogonadism?

A
  1. Congenital Primary Hypogonadism
    e.g. Turners (45X0)
    e.g. Premature Ovarian Insufficiency (POI)
  2. 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)
29
Q

What is polycystic Ovarian Syndrome?

A

“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)

30
Q

What are some complications of Polycystic Ovarian syndrome and how would you treat each complication?

A
  1. Irregular menses/ amenorrhoea (metformin, oral contraceptive pill, ovulation induction e.g. IVF)
  2. Insulin resistance & Impaired glucose homestasis like T2DM and gestational DM (metformin, diet & lifestyle changes)
  3. Hirsutism (Anti-androgens like spironolactone, creams, waxing, laser
  4. Increased endometrial cancer (progesterone courses)
31
Q

What are the key components of the history you need to diagnose the cause of female infertility?

A

Key History:
Duration
Previous children
Pubertal milestones
Menstrual History
Medications/drugs

32
Q

What are the key examinations you would conduct to diagnose the cause of female infertility?

A

Key Examination:
BMI
sexual characteristics
hyperandrogenism signs
anosmia

33
Q

What are the key investigations you would conduct to diagnose the cause of female infertility?

A
  1. Blood Tests:
    LH, FSH, PRL
    Oestradiol, Androgens
    Mid- Luteal Prog
    Karyotyping
  2. Pregnancy Test
    (urine or serum HCG)
  3. Imaging:
    US (transvaginal)
    Hysterosalpingogram
    MRI Pituitary
    (if low LH/FSH or high PRL)
34
Q

What is Turners Syndrome?

A

“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)

Endocrinology (14 decks)

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