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ENDOCRINE > Infertility > Flashcards

Infertility Flashcards

1
Q

Why is infertility increasing?

A 
older women
rise in increase in chlamydia infections
increase in obesity
increasing male factor infertility
increasing awareness of treatments
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2
Q

What is the definition of infertility?

A
  • failure to get pregnant
  • after 12 months or more
  • regular unprotected sexual intercourse
  • couple have never had a child
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3
Q

Describe the difference between Primary and Secondary Infertility

A

Primary = couple have never conceived

Secondary = couple have previously conceived, BUT pregnancy may not have been successful
=> e.g. miscarriage or ectopic pregnancy

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4
Q

What factors can increase the likelihood of getting pregnant?

A
  • Woman aged < 30
  • Previous pregnancy
  • < 3 years trying to conceive
  • Intercourse around time of ovulation
  • BMI 18.5 – 30
  • Both partners non-smokers
  • Caffeine intake < 2 cups of coffee daily
  • No use of recreational drugs
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5
Q

At what maternal age does the steep decline of fertility start?

A

Around the age of 35

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6
Q

Males account for 1/3 of infertility, whilst females account for the other 2/3 of infertility. TRUE/FALSE?

A

FALSE
1/3 male
1/3 female
1/3 combined

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7
Q

In what physiological situations would cause anovulatory infertility (no egg release)

A
  • before puberty
  • pregnancy
  • lactation (breastfeeding)
  • menopause
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8
Q

What gynaecological conditions can cause anovulatory infertility?

A

Hypothalmic Disorders:
=> anorexia/bulimia, excessive exercise

Pituitary Disorders:
=> hyperprolactinaemia, tumours, Sheehan syndrome

Ovarian Disorders:
=> PCOS, premature ovarian failure

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9
Q

What systematic disorder is known to cause anovulatory infertility?

A

chronic renal failure

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10
Q

What drugs can cause anovulation and therefore infertility?

A

Depo-provera (injection)
Nexplanon (implant)
Oral Contraceptive Pill

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11
Q

Can anorexia cause anovulation?

A

Yes

Causes low FSH, LH and Oestradiol

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12
Q

What are the clinical features of anorexia?

A

low BMI (below 18.5)
loss of hair
low pulse and BP
anaemia

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13
Q

How does Polycystic Ovary syndrome usually present?

A
  • obesity
  • hirsutism or acne
  • cycle abnormalities and infertility
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14
Q

What endocrine abnormalities are present in Polycystic Ovary Syndrome?

A

high free androgens
high LH
impaired glucose tolerance

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15
Q

What is the diagnostic criteria for Polycystic Ovary Syndrome?

A

2 out of 3 of:

  • chronic anovulation
  • polycystic ovaries
  • hyperandrogenism
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16
Q

What are the possible causes of premature ovarian failure?

A
  • idiopathic
  • genetic (Turner’s syndrome, fragile X)
  • chemotherapy/radiotherapy
  • oophorectomy (ovary removal)
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17
Q

How does premature ovarian failure present clinically?

A

hot flushes
night sweats
atrophic vaginitis

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18
Q

Describe the hormonal effects of premature ovarian failure?

A

high FSH
high LH
low oestradiol

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19
Q

What are the possible infective causes of tubal disease?

A
  • Pelvic inflammatory disease
    => chlamydia, gonorrhoea = most common

-Transperitoneal spread:
=> appendicitis, intra-abdominal abscess

  • Following a procedure:
    => IUCD insertion, hysteroscopy, HSG
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20
Q

What are the most common causes of tubal disease that are not from an infection?

A
  • endometriosis
  • surgical (sterilisation, ectopic pregnancies)
  • fibroids/polyps
  • congenital
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21
Q

What is a Hydrosalpinx?

A

Distended fallopian tube

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22
Q

What condition is characterised by the presence of endometrial glands outside uterine cavity?

A

Endometriosis

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23
Q

What symptoms are experienced in endometriosis?

A
  • dysmenorrhoea (cramps)
  • dysparenuia (pain during sex)
  • menorrhagia (heavy bleeding)
  • painful defaecation
  • chronic pelvic pain
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24
Q

What coital disorders can contribute to male factor infertility?

A

Erectile dysfunction

Ejaculatory Failure

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25
Q

What genetic conditions can cause male factor infertility?

A 
Kleinfelter Syndrome (XXY)
Y chromosome deletion
Immotile Cilia (e.g. CF)
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26
Q

Testicular torsions and varicoceles can cause what subtype of male factor infertility?

A

Vascular

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27
Q

What drugs can cause a decrease in male sperm count?

A
  • Alcohol, Tobacco, Marijuana, Cocaine
  • Testosterone Supplements
  • Specific chemo drugs
  • Long term use of certain antibiotics
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28
Q

What drugs can cause hormone imbalance?

A 
Marijuana
Testosterone supplements
Anabolic Steroids
Opiates
Spironolactone
Drugs for schizophrenia/ tri-cyclic antidepressants
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29
Q

What drugs can cause decreased sex drive?

A 
Excessive alcohol
SSRIs
Opiates
Spironolactone
Beta Blockers
Lithium
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30
Q

What drugs can cause erectile dysfunction?

A 
Excessive alcohol, Tobacco, Cocaine
Spironolactone and other diuretics 
Beta-blockers
Alpha-Blockers
Schizophrenia/ Tri-cyclic antidepressants
Lithium
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31
Q

Decrease ability of sperm to fertilise egg?

A
  • Ca channel blockers
  • Tetracyclic antibiotics
  • Drugs for gout
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32
Q

Describe the hormone profile in non-obstructive male infertility

A

High LH and FSH

low testosterone

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33
Q

What examinations are carried out on a female attending an infertility clinic?

A
  • BMI
  • Assessing body hair distribution
  • Galactorrhoea
  • Pelvic examination => assessing for uterine and ovarian abnormalities/tenderness/mobility
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34
Q

What examinations are carried out on a male attending the infertility clinic?

A
  • BMI
  • Genital examination
    => Assessing size/position testes
    => Penile abnormalities
    => presence vas deferens
    => presence varicoceles
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35
Q

What investigations should females experience at an infertility clinic?

A
  • endocervical swab for chlamydia
  • cervical smear if due
  • blood for rubella immunity
  • midluteal progesterone level progesterone
  • Test of tubal patency
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36
Q

What investigation is used to test tubal patency?

A

Hysterosalpingiogram

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37
Q

When is laparoscopy used to test tubal patency?

A

Known previous pathology:

  • ectopic pregnancy
  • ruptured appendix
  • endometriosis

Hx suggestive of pathology:

  • dysmenorrhoea
  • dysparunia
38
Q

When is hysteroscopy carried out?

A

Cases where suspected or known endometrial pathology:

i.e. uterine septum, adhesions, polyp

39
Q

What hormones should be tested for in an anovulatory cycle or infrequent periods?

A
  • Urine HCG
  • Prolactin
  • TSH
  • Testosterone and SHBG
  • LH, FSH and oestradiol
40
Q

How far apart should 2 semen analysis’ be carried out?

A

twice over 6 weeks apart

41
Q

What imaging modality can be used to visualise testicular cancer?

A

ultrasound

42
Q

Describe how GnRH is released from the hypothalamus

A

Pulsatile release

43
Q

Describe the difference in frequency of FSH and LH pulses

A 
FSH = low frequency pulses
LH = high frequency pulses
44
Q

How does FSH affect male and females differently?

A

FEMALES:

  • Stimulates follicular development
  • Thickens endometrium

MALE:

  • Stimulates sertoli cells
  • Spermatogenesis
45
Q

Describe the difference in the effects of LH in a male and female

A

FEMALE:

  • Peak stimulates ovulation
  • Stimulates corpus luteum development
  • Thickens endometrium

MALE:

  • Stimulates Leydig cells
  • Testosterone secretion
  • Spermatogenesis
46
Q

What phase of the menstrual cycle can be variable?

A

Follicular

47
Q

What do ovulation test kits measure?

A

LH surge

this usually occurs 36h before ovulation

48
Q

Where is oestrogen secreted from?

A

ovaries - follicle
adrenal cortex
(placenta in pregnancy)

49
Q

What structures secrete progesterone?

A

corpus luteum to maintain early pregnancy

placenta during pregnancy

50
Q

What effect does progesterone have on body temperature?

A

thermogenic effect => increases basal body temperature

51
Q

How is oligomenorrrhoea described?

A

cycles >35 days

52
Q

Describe the difference between Primary and Secondary Amenorrhoea

A

Primary - never had periods

Secondary - had periods that have now stopped

53
Q

How is a male with “no sperm” described?

A

azoospermia

54
Q

What aspects of sperm are studied when assessing spermatogenesis?

A

Sperm Count
Sperm Motility
Sperm Morphology

55
Q

How do the WHO classify causes of female infertility?

A

GROUP I - Hypothalamic pituitary failure
GROUP II - Hypothalamic pituitary dysfunction
GROUP III - Ovarian failure

56
Q

What are the main causes of hypothalamic/pituitary failure?

A
  • Stress
  • Excessive exercise
  • Anorexia / low BMI
  • Tumours
  • Head trauma
  • Kallman’s syndrome
  • Drugs (steroids, opiates)
57
Q

What BMI should females aim for when attempting to conceive ?

A

18.5 > 30

58
Q

What hormone therapies can be used to treat Group 1 of anovulatory disorders (Hypothalamic Pituitary failure)?

A
  • Pulsatile GnRH

- Gonadotrophin (FSH+LH) injections

59
Q

What are the advantages of Pulsatile GnRH Treatment?

A

90% women ovulate
82% pregnant in a year
Multiple preg rate not significantly increased

60
Q

What is the adverse effect of using FSH and LH injections?

A

higher multiple pregnancy rates

=> twins/triplets

61
Q

What hormones are found to be abnormal in Group 2 - Hypothalamic pituitary dysfunction?

A

LH in excess

GnRH and Oestrogen normal

62
Q

What is the most common disorder which falls under Group 2 Hypothalamic Pituitary dysfunction

A

Polycystic Ovary Syndrome

63
Q

Do most with Polycystic Ovary Syndrome present with Oligomenorrhoea or Amenorrhoea?

A

10-20% amenorrhoea

80-90% oligomenorrhoea

64
Q

Describe the Rotterdam criteria used for diagnosis of Polycystic Ovary Syndrome?

A
  • Oligo/Amenorrhoea

On ultrasound:

  • > 12 2-9mm follicles
  • Increased ovarian volume
  • Unilateral / bilateral
65
Q

What is the pre-pregnancy treatment used in Polycystic Ovary Syndrome?

A
  • Weight loss
  • Life style modification: smoking, alcohol
  • Folic acid 400 mcg / 5mg daily
  • Check prescribed drugs
  • Rubella immune
  • Normal semen analysis
  • Check fallopian tube is patent
66
Q

What drugs can be used for ovulation induction in PCOS?

A
  • Clomifene Citrate (Clomid)

alternatively Tamoxifen, Letrozole

67
Q

What days of the cycle is Clomifene given to induce ovulation?

A

Days 2-6

68
Q

Describe the mechanism of Clomifene and Tamoxifen

A

Prevents Oestrogen negative feedback

=> Stimulates GnRH and FSH/LH release

69
Q

What injection can be given to stimulate ovulation in PCOS?

A

Gonadotrophin Injections

70
Q

What are the advantages and disadvantages of Gonadotrophic Injections?

A

> Higher rates of ovulation and pregnancy than oral therapies
Risk of multiple pregnancy

71
Q

What therapy involves cautery to destroy parts of the ovary in the hope of inducing ovulation?

A

laparscopic ovarian diathermy

used in PCOS

72
Q

What percentage of PCOS patients become insulin resistant?

A

50-80%

73
Q

What improvements can Metformin make in insulin resistant PCOS patients?

A
  • Improves insulin resistance
  • reduces androgen production
  • Restoration of menstruation and ovulation
  • May increase in pregnancy rate
  • May improve sensitivity to clomifene
74
Q

What are the main risks of ovulation induction?

A
  • Ovarian hyperstimulation
  • Multiple pregnancy
  • Risk of ovarian cancer
75
Q

What groups are at increased risk of ovarian hyperstimulation in induced ovulation?

A

If <35 years old

PCOS Patients

76
Q

If a mother experiences a multiple pregnancy (twins etc) what symptoms she at increased risk of?

A

Hyperemesis
Anaemia
Gestational Diabetes
Pre-eclampsia

77
Q

If a mother experiences a multiple pregnancy (twins etc) what specific pregnancy complications she at increased risk of?

A
  • miscarriage
  • Low birth weight
  • Prematurity
  • Disability
  • Stillbirth / neonatal death
  • Twin-twin transfusion syndrome
78
Q

What disabilities are most likely to be associated with twin births?

A

cerebral palsy
impaired sight
congenital heart disease

79
Q

Describe the hormone profile of a patient with ovarian failure?

A
  • High gonadotrophins
  • Raised FSH
  • Low oestrogen
80
Q

What physiological situation is considered ovarian failure?/

A

Premature Menopause

female runs out of eggs

81
Q

What can cause premature ovarian failure?

A
  • Genetic => Turner’s/Fragile X
  • Autoimmune ovarian failure
  • Bilateral oophrectomy
  • Pelvic radio/chemotherapy
82
Q

What treatments are offered in premature ovarian failure?

A
  • HRT
  • Egg/Embryo donation
  • cryopreservation prior to chemo/radiotherapy
83
Q

What are the main causes of testicular failure?

A
  • Klinefelters (47XXY)
  • Y chromosome microdeletion
  • undescended testes
  • trauma / torsion / mumps
  • cancer
  • Pelvic radio/chemotherapy
  • Autoimmune disease
84
Q

What level of Prolactin indicates hyperprolactinaemia?

A

> 1000 iu/l on 2 or more occasions

85
Q

What class of drug is used to treat hyperprolactinaemia?

A

dopamine agonist

e.g. cabergoline

86
Q

If the sperm is injected int the egg for fertilisation, what is this process called?

A

Intracytoplasmic sperm injection (ICSI)

87
Q

What procedure involves the introduction of sperm to the uterus artificially?

A

Intrauterine Insemination

88
Q

If a baby was to present with rubella (due to mother not being vaccinated) what symptoms can be seen?

A

Widespread Rash
Microcephaly (brain)
Cataracts
Patent Ductus Arteriosus

89
Q

What warning should be given when administering the rubella vaccine to females of child-bearing age?

A

Dont get pregnant within few months of getting the vaccine due to it being a LIVE formula

90
Q

What treatments can be given for chlamydia infection?

A

Azithromycin

Doxycycline (if macrolide allergy)

91
Q

What clinical signs can indicate a potential diagnosis of PCOS?

A

Central obesity
Hirsutism
Acne

92
Q

Male sperm count is declining. TRUE/FALSE?

A

TRUE

ENDOCRINE (22 decks)

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