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Endo > 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.’

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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
Q

What is the treatment for hyperprolactinaemia

A

Dopamine agonist - cabergoline
Surgery/ DXT

26
Q

What are the signs of Klinefelter’s syndrome

A

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
Q

What do you do to diagnose male infertility

A

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
Q

What are treatment options in terms of male infertility

A

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
Q

What pattern would you see in premature ovarian insufficiency?

A

LH and FSH up
Oestradiol down

30
Q

What are symptoms for premature ovarian insuffiency?

What are the causes

A

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
Q

What pattern would you see in Anorexia Nervosa-Induced Amenorrhoea

A

All down

32
Q

In female infertility, what causes problems in the Gonads

A

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
Q

How do you diagnose Polycystic ovarian syndrome

A

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
Q

What are consequences of POS

A

Irregular menses / amenorrhoea
–> Infertility

Metabolic:
↑ Insulin resistance
–>Impaired glucose homeostasis
(T2DM, gestational DM)

Hirsutism
↑ Endometrial cancer risk (2-6)

35
Q

What is the treatment for POS?

A

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
Q

What are the symptoms in Turner’s syndrome (45 X0)

A

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
Q

What do you do to diagnose female infertility

A

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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