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Infertility Flashcards

1
Q

Meanings

Fertility

A

measure of the actual outcome of the reproductive process

  • number of children born to an individual/couple.
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2
Q

Meaning

Fecundity

A

measure of the ability to conceive AND produce a live birth.

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2
Q

Meanings

Fecundability

A

probability of conceiving each month - the monthly chance of pregnancy, or monthly fertility rate

-either for an individual (measured over time)
-or for a population (the number of conceptions occurring in one month).

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3
Q

Meaning

Infertility

A

The inability to conceive after a period of unprotected intercourse or the inability to carry a pregnancy to term.

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4
Q

Meaning

How does NICE define infertlity

A

defined as failing to get pregnant after two years of regular unprotected sex

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5
Q

Meanings

Subfertility

A

A state of reduced fertility.

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6
Q

When do people typically advice medically

A

one year -> subfertlity

most couples are unaware of fertility status until trying for child

Of 100 couples without a fertility issue trying to conceive naturally:
20 will conceive within one month
70 will conceive within six months
85 will conceive within a year
90 will conceive within 18 months
95 will conceive within two years

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6
Q

How many couples have difficulty concieving?

A

1 in 6

Infertility commonest reason for women aged 20-45 to see their GP

majority may become naturally pregnant down the line (if you try early enough)

Only 20% of these cases arise through actual sterility

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7
Q

What factors can affect fertility

A
  • Age
  • Smoking status
  • Obesity
  • Increasing prevalence of STIs such as chlamydia

chlamydia: are damaging the reproductive tract and so reduce fertility

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8
Q

If a couple turn up and ask about concieving what is the first you should do

A
  • ASK: how long have you been trying
  • family history
    • is there lots of miscarriages
  • current sexual history
    • do they know they are ovulating,
    • are they are trying correctly
  • past sexual history
    • whats its like with other partners
    • may not always say things in front of their other partners
    • if a female says they got pregnant, its smth you can rely on it, whereas men may say they have fathered pregnancy … (???)
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9
Q

What females factors can affect conception

like physiologically

A
  • Ovulatory disorders
  • Tubal damage
  • Endometriosis
  • Uterine abnormalities
  • Implantation, growth and development
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10
Q

Female

What tests would be conducted

A
  • via blood analysis
    • FSH, LH (day 2-4) -> check ovarian reserve
    • day 21 progesterone -> to investigate ovulation
  • via ultrasound (laparoscopy, or radiogram)
    • hysterosalpingogram
    • dye spill means the fallopian tube is clear, the egg can go down, and sperm can go up
    • Laparoscopy
    • involves looking inside the abdomen to visualize the uterus, fallopian tubes and ovaries
    • to check they have normal appearance.
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11
Q

What are the causes of infertlity in women

A

Ovulation disorders (40%)

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12
Q

Meanings

Primary amenorrhoea

A

No cycles ever happened

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13
Q

Secondary amenorrhoea

A

occurs when a patient who has passed menarche goes six months or longer without menses

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14
Q

What is oligomenorrhoea

A

Irregular cycles

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15
Q

How would check for an anvoluatry cycle

A

take a day-21 progestorone

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16
Q

What other factors can ovulation disorders be associated with

things outside the body

A

ovulation disorders can be associated with stress, obesity, strenuous exercise, anorexia nervosa and drug use

stress axis is important

around 30% of cases, treatment with placebo is affective in getting cycles to resume and restoring fertility

Possible failure of maturation of neuroendocrine system at puberty can also cause annovulation

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17
Q

What disorders can cause annovulation

A

**Idiopathic ovarian failure
**
- Gonadotrophin secretion is normal but is insufficient to support a normal cycle → end organ insensitivity
- oestrogen levels fail to rise and follicles fail to mature (many small follicles)

**Polycystic ovarian syndrome (PCOS)
**
- Associated with LH and usually increases androgens (mild increase in follicular phase)

**Anovulatory cycles – endocrinologically normal
**
- Luteinised unruptured follicle syndrome (LUF) – eggs ‘deficient’

**Abbreviated luteal phase
**
- decreased Progesterone →poor luteinization
- you don’t maintain endometrium

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18
Q

What disorders of the female tract can impact conception

A

**Tubal obstruction
**- can be due to
- secondary consequence of pelvic infection
- increase the incidence of STDs, e.g gonorrhoea, chlamydia and tuberculosis
- Post-abortal or post-pregnancy sepsis
- scarring may affect surface of fallopian rube, can affect sperm going up, or egg going down
- infection → impaired oocyte and sperm transport due to loss of cilia on intraluminal cells and scarring => adhesions

  • Endometriosis
    • endometrial tissue growth escalates in ectopic sites – oviduct, ovary or peritoneal cavity => scarring/adhesions
    • pain
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19
Q

female

Apart from ovulation and tubal disorders what other factors can affect pregnancy

A
  • cervical incompetence
  • implantation defects
  • autoimmune (lupusP
  • immunological incompatibly
    • rhesus, ABO

Basically, can get prgenant but something downstream is affecting it

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20
Q

How do we detect a pregnancy biochemically and clinically

A

**- biochemical pregnancy
** - tested with the presence of hCG in blood and urine after 18-30 days start of last period
**- clinical pregnancy
** - ultrasound at 5 weeks
- foetal heart at 7 weeks

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21
Q

What are the two types of loss

A

-sponetanous
-abnormal conceptus

22
Q

How does a sponetnous loss occur after a clinical pregancy

after 5-7 weeks

A
  • 4/5 cycles involving unprotected intercourse don’t cause pregnancy
    • when sperm meets egg it may not always implant

  • flushing of the human uterus revealed that at day 4/5 only 20% of embryos recovered where blastocysts
  • 15-25% of clinical pregnancies fail (1st trimester)
23
Q

What percentages of pregnancies end up in a live birth

A

15-25% have a live birth

24
Q

Why does pregnancy loss due to abnormal conceptus happen

A

60% of the time, have sponetonus abortion because the sperm or egg gave the wrong amount of chromosomes

Chromosomal abonromalities types
-Translocations
-Errors of ploidy
-Deletions or duplications of a complete set of haploid chromosomes
Errors of chromosome number or ‘somy’

25
Q

How can age affect conception

A
  • as females gets older
    • chance of miscarriage goes up
    • live birth goes down
    • aneuploidy in oocyte is more common
    • this is related to egg quality, not he uterus, or endometrium

if we give a lady of 44 a donor egg, she will have same chance of pregnancy and no increased risk of miscarriage.
I.e. as you age, egg quality decreases -> aneuplodiy point

26
Q

What are the effects of delayed reproduction

causes

A
  • caused by age-related factors
    • diabetes
    • hypertension
  • increase in miscarriage and imprinting disorders go beyond 45 years
  • increase of autism increases as men get older
27
Q

What happens with egg and sperm as they both get older

A

as eggs get older, the eggs struggle to deal with problems older sperm brings them

-miscarriages

28
Q

How can male disorders about sperm

so what about sperm can it affect

A
  • Production of spermatozoa
  • Transport of spermatozoa
  • Transmission of spermatozoa
  • Sperm function in the female tract
  • Fertilization and events afte
29
Q

What could be causing male infertitiy

A
  • dentify potentially correctable conditions
    • Ductal obstruction or hypogonadotropic hypogonadism
      • can you give gondotrophins and spermtagonsis may start
  • Identify potentially irreversible conditions requiring assisted reproductive technique using the sperm of the male partner.
    • like he’s doesn’t have a VAS and you can use a technqiye to get a around that
  • Identify irreversible conditions for which donor insemination or adoption are the possible options
  • identify life-threatening conditions
    • testicular cancer, pituitary tumours
  • identify genetic abnormalities that may affect the health of offspring if assisted reproductive techniques should be employed
30
Q

What tests do you need to do intially for men

A
  • reproductive history
  • semen analysis
    • one semen analysis
    • if it comes with abodnomal result
      • if he gives a reason, like i had the flu, or smth then do a repeat
  • additional blood analysis
31
Q

male infertility

What examinnations

A

Examine male

  • General weight, BP, urinalysis
  • Secondary sexual characteristics
    • does he loo like he’s gone through puberty
  • Signs of endocrine disease
  • Gynaecomastia
  • Abdominal examination
  • Genital examination
  • Digital PR
    • unusual in UK
    • you would check for prostatitis
32
Q

What endocrine evaluation would you do

A
  • abnormally low sperm count (5 million)
  • if he says he has impaired sexual function you would do bloods as soon as possible
  • other clinical findings
33
Q

Definitions

normozoospermic

A

normal semen sample
>16 million spermatozoa/ml; >30% rapid forward progressive motility and >4% normal morphology

34
Q

Defintions

Oligozoospermic

A

low sperm count

<16 million spermatozoa/ml

35
Q

Defintions

Asthenozoospermic

A

about sperm motlity -> reduced motlity
< 42% rapid and normal forward progressive motility

36
Q

Teratozoospermic

A

a condition in which a man has a high amount of abnormal shaped sperm

< 4% spermatozoa with normal morphology

37
Q

azoospermic

A

means no sperm in ejaculate

38
Q

what does zoospermic mean

A

to do with sperm

39
Q

if there is a problem with the ejaculate

A

spermia

40
Q

What are the causes of failure in sperm production

A

Congenital testicular deficiency
- Klinefelter (47, XXY)
- Y Chromosome deletions

Maldescended testes - cryptorchidism
- didn’t get normal testicular decent
- Reduced spermatogenesis
- Increased risk for testicular cancer

Acquired
- Trauma - testis torsion
- may have cut off the blood supply
- hit with cricket bat or smth
- Orchitis (mumps)
- Endocrine disorders

41
Q

What clinical tests can you do for sperm

A
  • leucocytes in semen over 1 million per ml
    • tells you man have some kind of infection
  • sperm viability tests
    • to test if sperm or dead or nah
  • sperm vitality tests
    • if sperm are alive, but they aren’t moving suggests, that sperm does not move
  • anti-sperm antibodies
  • computer aided sperm analysis
42
Q

What are non standard sperm tests

A
  • DNA damage (TUNEL / SCSA / SDFA / Comet assays)
  • Aneuploidy (usually chromosomes 13, 18, 21, X and Y)
  • OxidaAve Stress Tests (MiOxsys, Luminol, TOS, TAC)
  • Cervical mucus penetraAon(CMT) and the post coital test (PCT)
  • Hemizona assay
  • Acrosome reacAon (AR)
  • Zona free hamster egg sperm penetraAon (SPA)

(most people do non-standard tests are ripping them off)

43
Q

What can cause sperm to fail to transmit themselves

tranmsit: from penis to vagina

A
  • erectile dysfunction
    • will affect delivery of sperm to female tract
  • ejaculatory dysfunction
    • retrograde
    • defects of accessory sex glands
44
Q

Descirbe how ejaculations usually happens

A
  • Contraction of musculature of prostate
    • seminal vesicles and vas deferens => seminal fluid and sperm => move out through urethra
  • Under sympathetic nerve control
  • Contraction of urethral and pelvic floor musculature => ejaculation
  • the vesicular urethral sphincter closes bladder neck
    • need to close this
45
Q

What is reterograde ejaculation

A
  • Incompetence of urethral sphincter
  • Ejaculation into the bladder (retrograde)the path of least resistance
46
Q

What conditions are associated with reterograde ejaculation

A
  • Diabetes
  • post traumatic paraplegia
  • post bladder neck surgery
47
Q

What are the signs of reterograde ejaculatiomn

tests

A

Ejaculate volume nil or low
Confirmation in urine – see if sperm in urine.

48
Q

Why would you do a post ejaculatory urine analysis

A

low volume ejaculate
Absent ejaculate (Aspermia)

Avoid if CBAVD / hypogonadism features

49
Q

What are the causes of low volume / no ejaculate:

A
  • retrograde ejaculation
  • Lack of emission
  • Ejaculatory duct obstruction
50
Q

sperm

What can cause a total failure in transport

A
  • post-infection
    • bilateral epididymal/ vas occlusion
      • can be injury or by an STI
  • congenital bilateral absence of vas defferns
    • CBAVD
    • ejaculate he thinks is normal, but there’s no sperm in ejauclate
  • Azoospermic semen samples – obstructive azoospermia
51
Q

What are the indications for genetic testing

A
  • genetic abnormalities may cause infertility
    • they can affect sperm production or transport
    • Chromosomal abnormalities resulting in impaired testicular function. Klinefelter’s or translocations or inversions.
  • men with non obstructive azoospermia, or oligozoospermia
52
Q

What do 10-15% of men with severe oligo or azoospermia have

A

Y chromosome microdeletion

if the man goes onto have a son, the son may have the same phenotype or worse

53
Q

What is CNAVD

what is it associated with causes etc

A
  • Linked to CFTR gene (causes Cystic Fibrosis)
  • CFTR gene mutation on chromosome 7
  • CF associated with CBAVD.
  • It is an improper development of vas deferens (c.f. vasectomy)
  • > 95% of men with CF have CBAVD

85% of men with CBAVD have only one severely mutated allele => no other CF symptoms… In this situation you can take sperm for testes or epididymis and perform assisted reproduction.

  • Check female partner when relevant
    • but if she has a CF mutation, there’s a 25% chance they would make a baby with CF
54
Q

What is the sperms role in fertilisation

A

– Centriole function (spindle formation)

– Chromatin decondensation

– Protamine exchange

– Pronuclear fusion

– Activation of genes for placenta formation

if you can select the sperm, you can skew the odds of things workings

55
Q

What is the unexplained infertility …

A

it is when - Normal frequency and distribution of unprotected intercourse
- No obstructions of malformations in female or male genital tracts
- Normal follicle growth, maturation and ovulation; no signs of ongoing inflammatory reactions
- Normal concentration of motile spermatozoa, no anti-sperm antibodies or other signs of ongoing inflammatory reaction is …

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