Infertility Flashcards
What is infertility?
Failure to achieve clinical pregnancy after 12 months of regular (every 2-3 days) unprotected sex
What is the difference between primary and secondary infertility?
Primary - not had birth previously,
Secondary - previous pregnancy >12 months ago
What is the percentage of couples that have infertility?
14%
What percentage of causes are male, female, both, unknown?
30% - male/female/both
10% - unknown
What is the impact on couples that infertility?
Psychological distress - not having baby, investigations & treatment stress
Impact on society
Less births,
Less tax for govt
Expensive treatment to fund
What are the three groups of causes of infertility in men?
Pre-testicular, testicular, post-testicular
What are examples of pre-testicular causes?
Congenital (Klinefelters, extra X chromosome),
Acquired (HPG, testosterone, PRL issues)
What are examples of testicular causes?
Cryptorchidism,
Infection (STDs),
Immunological (antisperm antibodies),
Vascular (varicocoele),
Trauma/Surgery,
Toxins (radiotherapy)
What are examples of post-testicular causes?
Congenital (absence
of van deferens in cystic fibrosis)
u
Obstructive (no sperm in semen),
Erectile Dysfunction, Latrogenic (vasectomy)
What is cryptorchidism?
Testis does not pass through inguinal canal into scrotum
What are the six groups of causes of gonadal infertility in women (and relative percentages)?
Ovarian (40%),
Tubal (30%),
Uterine (10%),
Cervical (5%),
Pelvic (5%),
Unknown (10%)
(start from ovaries and work your way down)
What are examples of ovarian causes?
Anovulation, Corpus Luteum Insufficiency
What are examples of tubal causes?
Tubulopathy - endometriosis, trauma
What are examples of uterine causes?
Congenital malformations, Fibroids, Infection/Scarring/Inflammation
What are examples of cervical causes?
Ineffective sperm penetration - infection/inflammation, immunological (antisperm antibodies)
What is endometriosis?
Presence of functioning endometrial tissue outside uterus
What are the symptoms of endometriosis?
Menstrual pain, menstrual irregularities, deep dyspareunia (pain during sex), infertility
What are fibroids?
Benign tumours of myometrium
What hormone affects fibroids and endometriosis?
Oestrogen - growth fibroids
What are the symptoms of fibroids?
Usually asymptomatic but can be same as endometriosis (increased menstrual pain, irregularities, deep dyspareunia, infertility)
HPG Axis
Kisspeptin neurones stimulate
Gnrh neurones
Gnrh released in a pulsatile manner, to the hypophyseal portal circulation
Anterior pituitary gonadotrophs secrete LH/FSH pulsatile
Enter systemic circulation and go to the gonads
Diurnal release of testosterone and oestrogen
What are four examples of hypogonadotrophic hypogonadism?
Anosmic Kallman Syndrome (congenital),
Acquired (low BMI, stress, exercise), Hyperprolactinaemia, Hypopituitarism
Effect of hyperprolactinanemia
Prolactin inhibits HPG axis
Low LH/FSH/T
How do you treat acquired hypogonadotrophic hypogonadism?
Lifestyle changes (not medication)
What are two examples of primary hypogonadism?
Klinefelter’s Syndrome 47XXY (Congenital),
Acquired (testicular causes)
How does Kallmann’s Syndrome work?
Migration of GnRH neurons from embryological olfactory placode (primitive nose) to hypothalamus is blocked - GnRH system does not form
Why does Kallmann syndrome cause anosmia?
Olfactory nerve cells also have to migrate from the olfactory placode but cannot, therefore the sense of smell cannot be developed
Hypothalamic causes of male infertility
Low Gnrh, LH, FSH, T
Congenital hypogonadotrophic hypogonadism (Kallmann’s)
Acquired hypo hypogonadism (low BMI, XS exercise, stress)
Hyperprolactinaemia
What are 4 presentations of Klinefelters syndrome?
Tall stature,
low facial hair,
small penis/testes,
low bone density
Pituitary causes of male infertility
Low LH/FSH/T
Hypopituitarism, (tumour, apoplexy, infiltration, surgery, radiation)
What questions from history do you need to ask infertile men?
Duration of symptoms, previous children, puberty milestones, medications/drugs
Why do you need morning fasting testosterone?
Morning - diurnal rhythm highest in morning // Fasting - carbohydrates can suppress testosterone
What do you need to examine for male infertility?
BMI, sexual characteristics, testicular volume, anosmia
What investigations do you need to do for male infertility?
Semen analysis (volume, sperm concentration), blood tests (FSH/LH/PRL, morning fasting testosterone), karyotyping, Scrotal Ultrasound // MRI Pituitary
What are the general lifestyle measures that should be taken for treating infertility?
Optimise BMI, Smoking Cessation, Alcohol Cessation
What are the medical treatments for male infertility?
Dopamine agonists for hyperprolactinaemia, gonadotrophin treatment, surgery (sperm extraction)
Why would you not give a testosterone injection here?
Testosterone lowers FSH and LH levels, FSH and LH needed for spermatogenesis, therefore fertility is reduced if testosterone is given
What are three causes of POI?
Autoimmune,
Genetic (Turner’s Syndrome), Cancer therapy
What is POI?
Premature ovarian insufficiency - ovaries are unable to produce oestrogen, but FSH/LH very high
Cessation of menstruation before 40 years of age
Gonadal causes of male infertility
Congenital primary hypogonadism (Klinfelters 47XXY)
Acquired primary hypogonadism (Cryptorchidism, trauma, chemo, radiation)
What are the causes of primary hypogonadism in women?
PCOS //
POI (Acquired)
// Turners Syndrome (Congenital) XO
How common is PCOS?
5-15% of reproductive age, most common endocrine disorder and cause of infertility in women
What is the criteria system for PCOS diagnosis called and what are the components?
Rotterdam Diagnostic Criteria: Oligo or Anovulation, Hyperandrogenism,
Polycystic Ovaries - check with blood test
What are the five consequences of PCOS?
Amenorrhea, Infertility, Insulin Resistance, Hirsutism, Endometrial Cancer (tissue is not shed)
What are the treatments for PCOS?
Oral contraceptive pill (amenorrhea),
IVF (fertility),
metformin (improve insulin resistance, fertility), anti-androgens (hirsutism - spironolactone),
progesterone courses (endometrial cancer -shed endometrium less often)
What are oestrogen levels like in PCOS?
Depends on patient, but usually normal as some testosterone is converted to oestrogen (using aromatase), however in obese patients oestrogen is low
What is Turners Syndrome?
45X0 (born without one X chromosome)
What are the 6 presentations of Turners Syndrome?
Short stature,
brown nevi (spots),
amenorrhea,
underdeveloped reproductive tract,
poor breast development, coarctation of aorta (narrow aorta)
What are the history questions needed for female infertility?
Duration, previous children, puberty milestones, menstrual history, medication
What are the examinations needed for female infertility?
BMI, sexual characteristics, hirsutism, anosmia
What are the investigations needed for female infertility?
Blood tests (LH, FSH, PRL, Oestradiol, Mid-Luteal Progesterone - shows presence of corpus luteum and hence ovulation would have worked) // Pregnancy Test // Ultrasound or Pituitary MRI
