Infertility Flashcards
What part of the sperm forms the:
a) Acrosome?
b) Flagellum?
a) Golgi apparatus
b) Centriole
The acrosome of the sperm contains many of the lytic proteins which are required for what?
Digestion of the zona pellucida of the egg
Where does the egg settle in fertilisation?
The ampulla of the fallopian tube
What is capacitation? Where does it occur?
The penultimate stage of maturation of the sperm, occurring in the female genital tract, taking 5-7 hours
Sperm penetration of the egg has what 3 effects?
Triggers the egg to complete meiosis, a cytoplasmic rearrangement, increased metabolic activity
A dramatic increase in the levels of what in the egg shortly after the sperm makes contact acts as a secondary messenger to initiate changes?
Free intracellular Ca++
What is the association between chlamydia infection and infertility?
1 infection = 10% chance of tube damage, 3 infections = 50% chance of tube damage
What defines infertility?
Failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sex in couple who have never had a child (in the absence of a known reason)
What is primary infertility?
The couple have never conceived before
What is secondary infertility?
The couple have conceived before, even if the pregnancy was unsuccessful
What implies a good prognosis in infertility?
Woman is < 30, short duration of infertility, secondary infertility
What implies a bad prognosis in infertility?
Male infertility, endometriosis, tubal factor infertility
What must both halves of the couple not do in order to get NHS infertility treatment? Why is this?
They cannot smoke- as either individual smoking halves the chance of a pregnancy
What are some physiological causes of infertility in a woman?
Before puberty, pregnancy, lactation, menopausal
What are some hypothalamic causes of infertility in a woman?
Anorexia/bulimia, excessive exercise
What are some pituitary causes of infertility in a woman?
Hyperprolactinoma, tumours, Sheehan’s syndrome
What are some ovarian causes of infertility in a woman?
PCOS, premature ovarian failure
Apart from hypothalamic, pituitary and ovarian problems, what are some other causes of infertility in a woman?
Systemic disease (e.g. renal failure), endocrine disorders, CAH
What are the levels of FSH/LH/oestrogen in someone with anorexia?
All low
If a patient with anorexia does get pregnant, what is likely to happen?
Miscarriage or stillbirth
What are some infective causes of tubal disease?
Pelvic inflammatory disease, transperitoneal spread, following procedures
What is pelvic inflammatory disease?
Any infection of the female genital tract
What are some non-infective causes of tubal disease?
Endometriosis, surgical, polyps, congenital, SIN
What is salpingitis isthmica?
Diverticulitis of the Fallopian tube
What should you always screen for before intra-uterine procedures? What should you always give?
Screen for chlamydia, give prophylactic antibiotics
What is hydrosalpinx? What may this occur due to?
Distal Fallopian tube becomes blocked with fluid, can occur in PID
What are some clinical features of hydrosalpinx?
Pain, discharge, dyspareunia, menorrhagia and dysmenorrhoea, infertility
What is the treatment for tubal disease? What does the outcome depend on?
Surgery- outcome depends on the amount of damage
What is endometriosis?
The presence of endometrial glands, outside the uterine cavity
What is the most likely cause of endometriosis?
Retrograde menstruation
What is retrograde menstruation?
When the menstrual blood flows through the fallopian tube and into the pelvic cavity instead of out of the body
How can endometriosis present?
Can be asymptomatic, or cause dysmenorrhoea, dyspareunia, menorrhagia, painful defecation, pain, infertility
What will a scan of the ovaries show in endometriosis?
‘Chocolate’ cysts
What are the 2 main groups of pre-testicular infertility?
Endocrine causes or coital causes
What are some endocrine causes of infertility in males?
Hypogonadotrophic hypogonadism, hypothyroidism, hyperprolactinaemia, diabetes
What are the 4 main groups of testicular infertility?
Genetic, congenital, vascular, immunological
What are some genetic causes of male infertility?
Kleinfelter’s, Y deletion, immotile cilia
Which types of male infertility are non-obstructive?
Pre-testicular and testicular
Will a vas deferent be present in non-obstructive male infertility?
Yes
Which type of male infertility is obstructive?
Post-testicular
What are the 2 groups of post-testicular infertility?
Epididymal, vasal
Which types of male infertility will have low testicular volume and decreased secondary sexual characteristics?
Non-obstructive (pre-testicular and testicular)
Which types of male infertility will have normal testicular volume and secondary sexual characteristics?
Obstructive (post-testicular)
What may be absent in post-testicular male infertility?
Vas deferens
What will be the levels of LH/FSH/testosterone in non-obstructive infertility in males?
High LH/FSH, low testosterone
What will be the levels of LH/FSH/testosterone in obstructive infertility in males?
Normal
What are some drugs which are prone to causing male infertility?
Spironolactone, beta blockers, lithium, anti-depressants (also alcohol, tobacco, marijuana)
What investigations would you use for female infertility?
Chlamydia screen, smear, rubella immunity, test tubal potency, mid-luteal progesterone levels
When is a hysterosalpingogram used to assess tubal patency?
If there are no risk factors of tubal or pelvic pathology, or if laparoscopy is contra-indicated
When is a laparoscopy used to assess tubal patency?
If there is possible or known pelvic pathology
When there is an abnormality on pelvic exam, what test should be done?
Pelvic ultrasound
What are some contra-indications to ovarian laparoscopy?
Obesity, previous pelvic surgery, Crohn’s
When should semen analysis be tested in male infertility?
Twice over 6 weeks apart
If there is severely abnormal semen analysis in males, what tests should be done?
Chromosome analysis, screen for CF, testicular biopsy
If there is an abnormality on a male genital exam, what test should be done?
Scrotal ultrasound
What is the first line treatment for ovarian induction? Give examples.
Anti-oestrogens (clomifene crate, tamoxifen) and aromatase inhibitors (letrozole)
When should anti-oestrogen be taken?
Day 2-6 daily
What is the maximum dose of clomifene citrate daily?
150mg
What are some second line treatments for ovarian induction?
Clomifene citrate and metformin, gonadotrophin daily injections, laparoscopic ovarian diathermy
When should surgery be used in male infertility?
If the vas deferens is obstructed
Apart from surgery, what are some other options for male infertility?
Intrauterine insemination, donor sperm
How many times should ‘infertile’ couples have sex per week?
2/3
Females should limit alcohol to how many units a week?
4
BMI for both males and females should be between what?
19-29
What supplement should the female take?
0.4mg folic acid or 5mg if risk of tube defect
What should you always remember to check in the investigation of infertility (especially male)?
Drugs
