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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.’

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2
Q

What is primary infertility

What is secondary infertility

A

Not had a live birth previously

Have had a live birth > 12 months previously

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3
Q

What are psychological distress impacts of infertility on a couple

A
  • No biological child
  • Impact on couples wellbeing
  • Impact on larger family
  • Investigations
  • Treatments (often fail)
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4
Q

What is the cost to society of infertility

A
  • Less births
  • Less tax income
  • Investigation costs
  • Treatment costs
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5
Q

What are pre testicular causes of infertility in men

A

Congenital & Acquired Endocrinopathies
Klinefelters 47XXY

HPG, T, PRL issues

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6
Q

What are the testicular causes of infertility in men?

A

(Congenital)

Cryptorchidism

Infection STDs

Immunological Antisperm Abs

Vascular Varicocoele

Trauma/Surgery

Toxins
Chemo/DXT/Drugs/Smoking

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7
Q

What are the post-testicular causes of infertility in men?

A

Congenital Absence of vas deferens in CF

Obstructive Azoospermia

Erectile Dysfunction -
Retrograde Ejaculation
Mechanical Impairment
Psychological

Iatrogenic Vasectomy

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8
Q

What is cryptorchidism?

A

Normal path for testis descent is from abdomen through inguinal canal to testicular sac

Undescended testis (90% of this is in the inguinal canal)

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9
Q

What are causes of infertility in women

A

Ovarian Causes (40%)
-Anovulation (Endo)
-Corpus luteum insufficiency - insufficient progesterone so failure to implant

Pelvic Causes (5%)
-Endometriosis
-Adhesions

Tubal Causes (30%)
Tubopathy due:
-Infection
-Endometriosis
-Trauma

Uterine Causes (10%)
Unfavourable endometrium due:
-Congenital malformations
-Infection/Inflammation/Scarring (adhesions)
-Fibroids

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

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10
Q

What is endometriosis?

A

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

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11
Q

What are the symptoms of endometriosis?

A

↑ Menstrual pain
Menstrual irregularities
Deep dyspareunia
Infertility

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12
Q

What are fibroids?

A

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

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13
Q

What are the symptoms of fibroids?

A

Usually asymptomatic
↑ Menstrual pain
Menstrual irregularities
Deep dyspareunia
Infertility

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14
Q

Explain the HPG axis

A

Kisspeptin neurones secrete kisspeptins that binds to GnRH neurones and then that causes secretion into the hypophyseal portal circulation
That causes LH and FSH to be released from the gonadotrophs
That then causes testosterone or oestrogen to be produced in the gonads

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15
Q

What are causes of hyperprolactinaemia

A

Tumour - micro/macro

Macro can press optic chiasm just above pituitary

Pregnancy

Medications - dopamine antagonists

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16
Q

What happens in hyperprolactinaemia

A

LH AND FSH AND TESTOSTERONE all down

17
Q

What patterns would you see in primary testicular failure? e.g. Klinefelter’s Syndrome

A

LH and FSH up
Testosterone down

18
Q

What happens in hypogonadotropic and hypogonadism?

Where

A

Lower GnRH
Lower LH and FSH
Lower T

Hypothalamus and anterior pituitary

19
Q

What happens in hypergonadotropic and hypogonadism?

A

LH and FSH up
T down

In Gonads

20
Q

What causes problems in hypothalamus for infertility

A

Congenital Hypogonadotrophic Hypogonadism
-Anosmic (Kallmann Syndrome) or Normosmic

Acquired Hypogonadotrophic Hypogonadism
-Low BMI, XS exercise, Stress

Hyperprolactinaemia

In women: hypothalamic ameneorrhoea

21
Q

What causes problems in the anterior pituitary infertility

A

Hypopituitarism
-Tumour, Infiltration, Apoplexy, Surgery, Radiation

22
Q

What causes problems in men in the gonads infertility

A

Congenital Primary Hypogonadism
-Klinefelters (47XXY)

Acquired Primary Hypogonadism
-Cryptorchidism, Trauma, Chemo, Radiation

23
Q

Explain Kallmann Syndrome

A

Failure of migration of GnRH neurons with olfactory fibres from olfactory placode (primitive nose) to hypothalamus

Low GnRh
Low LH and FSH - hypogonadotrophic
Low T - hypogonadism

Anosmia
Failure of puberty
Infertility

24
Q

How does hyperprolactinaemia inhibit kisspeptin neurones

A

Prolactin binds to prolactin receptors on kisspeptin neurons in hypothalamus

Inhibits kisspeptin release.

Decreases downstream GnRH/LH/FSH/T/Oest

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

25
What is the treatment for hyperprolactinaemia
Dopamine agonist - cabergoline Surgery/ DXT
26
What are the signs of Klinefelter's syndrome
Tall stature ↓ Facial hair Breast development Female-type pubic hair pattern Small penis & testes Infertility (accounts for up to 3% of cases) Mildly impaired IQ Narrow shoulders Reduced chest hair Wide hips Low bone density High LH and FSH, low T
27
What do you do to diagnose male infertility
Key History: duration, previous children, pubertal milestones, associated symptoms (eg. T deficiency, PRL symptoms, CHH features), medications/drugs Key Examination: BMI, sexual characteristics, testicular volume, anosmia Key Investigations: Semen Analysis: Blood Tests: LH, FSH, PRL Morning Fasting Testosterone - carbohydrates can supress it Karyotyping Imaging: Scrotal US/Doppler (for varicocoele/obstruction, testicular volume) MRI Pituitary (if low LH/FSH or high PRL)
28
What are treatment options in terms of male infertility
General Lifestyle Optimise BMI Smoking cessation Alcohol reduction/cessation Specific Treatment: 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))
29
What pattern would you see in premature ovarian insufficiency?
LH and FSH up Oestradiol down
30
What are symptoms for premature ovarian insuffiency? What are the causes
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 Turner’s Syndrome Cancer therapy Radio- / Chemo-therapy in the past
31
What pattern would you see in Anorexia Nervosa-Induced Amenorrhoea
All down
32
In female infertility, what causes problems in the Gonads
Polycystic ovarian syndrome (normal or low E2) Acquired Primary Hypogonadism -Premature Ovarian Insufficiency (POI) -Surgery, Trauma, Chemo, Radiation Congenital Primary Hypogonadism -Turners (45X0) -Premature Ovarian Insufficiency (POI)
33
How do you diagnose Polycystic ovarian syndrome
Rotterdam PCOS Diagnostic Criteria (2 out of 3) Oligo or Anovulation -Normally assessed by menstrual frequency as oligomenorrhoea: e.g. <8-9 cycles/y Clinical +/- Biochemical Hyperandrogenism CLINICAL Acne, hirsutism, alopecia BIOCHEMICAL Raised androgens (eg Testosterone) Polycystic Ovaries (US)
34
What are consequences of POS
Irregular menses / amenorrhoea --> Infertility Metabolic: ↑ Insulin resistance -->Impaired glucose homeostasis (T2DM, gestational DM) Hirsutism ↑ Endometrial cancer risk (2-6)
35
What is the treatment for POS?
Oral contraceptive pill to help with irregular menses Ovulation induction - IVF to help with infertility Metformin to help with menses and with insulin resistance - diet and lifestyle will also help Anti androgens (e.g. spironolactone) and creams, waxing, laser for hirsutism Progesterone courses for endometrial cancer risk
36
What are the symptoms in Turner's syndrome (45 X0)
Short stature Low hairline Shield chest Wide-spaced nipples Short 4th metacarpal Small fingernails Brown nevi Amenorrhoea Characteristic facies Webbed neck Coarctation of aorta Poor breast development Elbow deformity Undeveloped reproductive tract Amenorrhoea Increase in LH and FSH Decrease in T
37
What do you do to diagnose female infertility
Key History: duration, previous children, pubertal milestones, menstrual History, medications/drugs Key Examination: BMI, sexual characteristics, hyperandrogenism signs, anosmia Key investigations: Blood Tests: LH, FSH, PRL Oestradiol, Androgens Mid- Luteal Prog Karyotyping Imaging: US (transvaginal) Hysterosalpingogram MRI Pituitary (if low LH/FSH or high PRL) Pregnancy Test (urine or serum HCG)

Endo (13 decks)

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