infertility Flashcards
definition of infertility
a disease of the REPRODUCTIVE SYSTEM defined by the failure to achieve A CLINICAL pregnancy after>12 months of REGULAR unprotected sexual intercourse.
what is considered regular intercourse
every 2-3 days
prevelance of infertility and how many achieve it after an extra year of trying
14% of couples but half of these will achieve after extra year
how many couples with infertility seek help?
55%
which couples have been shown to be more likely to seek help concerning infertility?
higher socioeconomic status
what proportion of cases is due to 1) male factor 2) female factor 3) combination of male AND female factor 4) unknown
1,2,3; 33% each, unknown :10%
what is the cost of infertility to society?
Less births
- Less tax income
- Investigation costs
- Treatment costs
what are some of the issues that trouble couples with infertility psychologically?
No biological child
- Impact on couples wellbeing
- Impact on larger family
- Investigations
- Treatments (often fail) (eg ivf- 20-30 % of success)– money and psych
Discouraging
what are the three main categories of male infertility causes?
pre-testicular
testicular
post-testicular
what are the causes of pre testicular infertility
congenital and acquired endocrinopathies
1) Klinefelters 47XXY (extra x chormosome)
2) HPG,
T,
PRL issues (prolactin)
CAUSES OF TESTICULAR INFERTILITY
(Congenital)
Cryptorchidism
Infection STDs
Immunological Antisperm Abs
Vascular Varicocoele
Trauma/Surgery
Toxins
Chemo/DXT/Drugs/Smoking
causes of post testicular infertility
Congenital: Absence of vas deferens in CF
Obstructive: (obstruction of spermatic cord): Azoospermia
Erectile Dysfunction:
1)Retrograde Ejaculation 2)Mechanical Impairment 3) Psychological
Iatrogenic: Vasectomy
what is the normal path through which testes descent?
inguinal canal
what happens in cryptorchidism?
undescended testes,
90% in ingiunal canal
what are the categories of female infertility causes?
cervical, uterine, tubal, ovarian, pelvic (things that can happen in multiple areas of the female reprod system)
what are some pelvic (general) causes of infertility
endometriosis
adhesions
tubal causes of infertility and prevalence
30% infection
endometriosis
trauma
uterine causes and prevalence
10% Unfavourable endometrium due:
-Congenital malformations
-Infection/Inflammation/Scarring (adhesions)
-Fibroids
cervical causes and prevalence
(5%)
Ineffective sperm penetration due:
-Infection/Inflammation
-Immunological (antisperm Ab)
ovarian causes of infertility and prevalence
40%
anovulation (endo)
corpus luteum insufficiency
rank the causes of female infertility for prevalence
1) ovarian 40
2) tubal 30
3) unexplained and uterine 10 each
4) pelvic and cervical 5 each
(remember it by location, from ovary to cervic physiological path) (ovary-> tube-> uterus-> cervix)
above what point in the fem reprod system is there sterility?
cervix
what is endometriosis?
presence of functioning endometrial tissue outside the uterus
prevalence of endiometriosis
5% of women
what can be given to help with endometriosis?
oestrogen
symptoms of endometriosis
MENSTRUAL pain
menstrual irregularities
deep dyspareunia (pain before during or after sex)
infertility
what are fibroids?
benign tumours of the myometrium
prevalence of fibroids and what factor increases their prevalence?
1-20% of premenopausal women (increases with age)
what do fibroids responf to and why?
oestrogen because they are mad eup of uterine tissue
usual presentation of fibroids
1) usually asymptomatic
2) incr menstrual pain
3) menstrual irregularities
dyspareunia
infertility
where is kisspeptin released form and where does it act on?
kisspeptin neurons in hypothalamus and acts on gnrh neurons in hypothalamus
which of the following are measurable in the blood? ( kisspeptin, gnrh and lh fsh)
only lh fsh
in what rhythm is gnrh released
pulsatile
what rhythm is lh and fsh released in
pulsatile
what rhythm is oestrogena nd testosterone release in
diurnal
is oestrogen produced from testosterone or test from oestrog by aromatisaiton
oestrog by testosterone (biology is sexist: way to remmebr)
levels of lh fsh and test in any endocrine male infertility issue caused by any part of the HPG axis above the pituitary (hypothal or pit)?
all low
(hypogonadotrophic hypogonadism)
(in hypothalamus issues gnrh is additionally low but it cant be measured anyways)
what do the terms: hypogonadotrophic hypogonadism mean and what is their significance?
hypogonadism : low test and oestrogen
hypogonadotrophic : low lh fsh
its not a diagnosis, just way to describe the situation
levels of lh fsh and test in any gonad level caused endocrine male infertility
test low, lh fsh high
hypothalamus level causes of endocrine male infertility?
congenital hypogonadotrophic hypogonadism (2 types-Anosmic (you cant smell) (Kallmann Syndrome) or Normosmic)
Acquired Hypogonadotrophic Hypogonadism
-Low BMI (anorexia nervosa: no , XS exercise, Stress
Hyperprolactinaemia
when are these symptoms (of klinefelters syndrome) even more severe?
when 3 or more x chromosomes are present
pituitary level causes of endocrine male infertility
Hypopituitarism
-Tumour, Infiltration (full of wbc), Apoplexy (blood flow interuption), Surgery, Radiation
gonad level causes of endocrine male infertility
Congenital Primary Hypogonadism
-Klinefelters (47XXY)
acquired primary hypogonadism Cryptorchidism, Trauma, Chemo, Radiation
what is kallmann syndrome?
the ANOSMIC type of CONGENITAL HYPOGONADOTROPHIC hypogonadism (at the HYPOTHALAMIC level)
main symptoms of kallmann syndrome?
anosmia
reproductive features:
failure of puberty (Short, small penis)
infertility
what is the pathology in kallmann syndrome
failure of migration of GnRH neurons with olfactory fibres from the olfactory placode (promitive nose) to the hypothalamus
how does hyperprolactinaumia work?
prolactin binds on prolactin receptors on kisspeptin neurons inhibits kissp and the axis
symptoms of hyperprolactinaemia in both men and women
(hypogonadal symptoms)
oligo or amenorrhoea
low libido
infertility/ osteoporosis
what is klinefelter syndrome?
most common sex chromosome disorder - (sex chromosome trisomy) people have an extra x chromosome
how common is klinefelter syndrome and how many cases get diagnosed?
1-2/ 1000 BIRTHS AND only 1/4 gets diagnosed
what are the symptoms in klinefelters syndrome?
tall stature
mildly impaired IQ (15 POINTS DOWN ON AVERAGE)
low bone density
and female looking stuff:
1) female pubic pattern
2) small penis and testes
3) wide hips
4) narrow shoulders
5) little facial + chest hair (infrequent shaving)
key history of male infertility
duration,
previous children,
pubertal milestones
key examination of male infertility
BMI
sexual characteristics
testicular volume
anosmia
key investigations for male infertility
1) semen analysis
2) blood tests
3) imaging
normal semen volume, sperm concentration and total motility (proportion of sperm that can move)
1.5 ml
15 million
40%
blood tests needed for male infertility
LH FSH PRL (prolactin)
Morning fasting testosterone
karyotyping
imaging tests in male infertility
MRI pituitary (if low fsh/ lh or high prl)
SCROTAL US (ultrasound) / doppler: checks blood flow) (if variococoele/ obstruction, testicular volume)
male infertility lifestyle treatments
Optimise BMI
Smoking cessation
Alcohol reduction/cessation
male infertility specific treatments
Dopamine agonist for hyperPRL
Gonadotrophin treatment for fertility (will also increase testosterone)
Surgery
(eg. Micro Testicular Sperm Extraction (micro TESE))
when do we give testosterone?
Testosterone
(for symptoms if no fertility required – as this requires gonadotrophins)
what is the first thing you do to women with infertility symptoms?
ensure not pregnant or breastfeeding first
symptoms of premature ovarian insufficiency
same as menopause
conception rate in POI
20%
causes of POI
Autoimmune
Genetic eg Turner’s Syndrome
Cancer therapy Radio- / Chemo-therapy in the past
what is the cause of gonad level endocrine female infertility with incr lh fsh and normal or low e2?
polycystic ovarian syndrome (PCOS )
HOW DO anorexia and stress induced amenorrhoea work?
Anorexia: no leptin: produced by fat cells
Stress: high cortisol: no periods
All these are sensed by kisspeptin neurons
Prevent periods bc its not safe to carry baby (if too thin or if too much stress)
what are the causes of gonad level endocrine female infertility with incr lh fsh and low e2?
Acquired Primary Hypogonadism
-Premature Ovarian Insufficiency (POI)
-Surgery, Trauma, Chemo, Radiation
Congenital Primary Hypogonadism
-Turners (45X0)
-Premature Ovarian Insufficiency (POI)
what is the most common speciifc cause of infertility in women?
PCOS - 5-15%, ALSO most common endocrine disorder in women
PCOS diagnostic mehtod
1) exclude other causes of infertility
2) rotterdam pcos diagnostic criteria 2/3:
a) oligo or anovulation (assessed by menstrual freq)
b) Clinical +/- Biochemical Hyperandrogenism
c) polycystic ovaries
PCOS symptoms
1) irregular menses/ amenorrhoea and infertility
2) incr insulin resistance and impaired glucose homeostasis (T2DM, gestational DM)
3) HIRSUTISM
4) incr risk of endometrial cancer
what drugs are given for PCOS to help with a mix of the symptoms?
1) OCP for lighter periods and improves risk for endometr cancer
2)ovulation induction (IVF ) for infertility
3) metformin and diet-lifestyle for insulin issues and irregular menses and weight loss
4) anti androgens and hair removal for hirsutism
5) progesterone for enfometrial cancer rik
what is turnners syndrome?
genetic disease cause of endocrine infertility (45 X)
SYMPTOMS of turners syndrome appearance
head:
low hairline,
certain facies (grimatses),
webbed (short) neck
whole body:
short,
brown nevi (big moles)
-nipples big distance apart + poor breast dev
hands:
(shield chest) short fourth metacarpal
small fingernails
elbow deformity,
health/ internal symptoms of turners syndrome
amenorrhoea
underdeveloped reproductive tract
what thing do you do differently for womens key history for infertility?
menstrual history
what do you do different for key for womens key examination for infertility?
hyperandrogenism signs
key investigations differences for infertility for women
1) OU DO PREG TEST FIRST: common and cheap
2)oestradiol, androgens, mid luteal progesterone
3)hysterosalpinogram in imaging
