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
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
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
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
5
Q
At what maternal age does the steep decline of fertility start?
A
Around the age of 35
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
7
Q
In what physiological situations would cause anovulatory infertility (no egg release)
A
- before puberty
- pregnancy
- lactation (breastfeeding)
- menopause
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
9
Q
What systematic disorder is known to cause anovulatory infertility?
A
chronic renal failure
10
Q
What drugs can cause anovulation and therefore infertility?
A
Depo-provera (injection)
Nexplanon (implant)
Oral Contraceptive Pill
11
Q
Can anorexia cause anovulation?
A
Yes
Causes low FSH, LH and Oestradiol
12
Q
What are the clinical features of anorexia?
A
low BMI (below 18.5)
loss of hair
low pulse and BP
anaemia
13
Q
How does Polycystic Ovary syndrome usually present?
A
- obesity
- hirsutism or acne
- cycle abnormalities and infertility
14
Q
What endocrine abnormalities are present in Polycystic Ovary Syndrome?
A
high free androgens
high LH
impaired glucose tolerance
15
Q
What is the diagnostic criteria for Polycystic Ovary Syndrome?
A
2 out of 3 of:
- chronic anovulation
- polycystic ovaries
- hyperandrogenism
16
Q
What are the possible causes of premature ovarian failure?
A
- idiopathic
- genetic (Turner’s syndrome, fragile X)
- chemotherapy/radiotherapy
- oophorectomy (ovary removal)
17
Q
How does premature ovarian failure present clinically?
A
hot flushes
night sweats
atrophic vaginitis
18
Q
Describe the hormonal effects of premature ovarian failure?
A
high FSH
high LH
low oestradiol
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
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
21
Q
What is a Hydrosalpinx?
A
Distended fallopian tube
22
Q
What condition is characterised by the presence of endometrial glands outside uterine cavity?
A
Endometriosis
23
Q
What symptoms are experienced in endometriosis?
A
- dysmenorrhoea (cramps)
- dysparenuia (pain during sex)
- menorrhagia (heavy bleeding)
- painful defaecation
- chronic pelvic pain
24
Q
What coital disorders can contribute to male factor infertility?
A
Erectile dysfunction
Ejaculatory Failure
25
What genetic conditions can cause male factor infertility?
```
Kleinfelter Syndrome (XXY)
Y chromosome deletion
Immotile Cilia (e.g. CF)
```
26
Testicular torsions and varicoceles can cause what subtype of male factor infertility?
Vascular
27
What drugs can cause a decrease in male sperm count?
- Alcohol, Tobacco, Marijuana, Cocaine
- Testosterone Supplements
- Specific chemo drugs
- Long term use of certain antibiotics
28
What drugs can cause hormone imbalance?
```
Marijuana
Testosterone supplements
Anabolic Steroids
Opiates
Spironolactone
Drugs for schizophrenia/ tri-cyclic antidepressants
```
29
What drugs can cause decreased sex drive?
```
Excessive alcohol
SSRIs
Opiates
Spironolactone
Beta Blockers
Lithium
```
30
What drugs can cause erectile dysfunction?
```
Excessive alcohol, Tobacco, Cocaine
Spironolactone and other diuretics
Beta-blockers
Alpha-Blockers
Schizophrenia/ Tri-cyclic antidepressants
Lithium
```
31
Decrease ability of sperm to fertilise egg?
- Ca channel blockers
- Tetracyclic antibiotics
- Drugs for gout
32
Describe the hormone profile in non-obstructive male infertility
High LH and FSH
| low testosterone
33
What examinations are carried out on a female attending an infertility clinic?
- BMI
- Assessing body hair distribution
- Galactorrhoea
- Pelvic examination => assessing for uterine and ovarian abnormalities/tenderness/mobility
34
What examinations are carried out on a male attending the infertility clinic?
- BMI
- Genital examination
=> Assessing size/position testes
=> Penile abnormalities
=> presence vas deferens
=> presence varicoceles
35
What investigations should females experience at an infertility clinic?
- endocervical swab for chlamydia
- cervical smear if due
- blood for rubella immunity
- midluteal progesterone level progesterone
- Test of tubal patency
36
What investigation is used to test tubal patency?
Hysterosalpingiogram
37
When is laparoscopy used to test tubal patency?
Known previous pathology:
- ectopic pregnancy
- ruptured appendix
- endometriosis
Hx suggestive of pathology:
- dysmenorrhoea
- dysparunia
38
When is hysteroscopy carried out?
Cases where suspected or known endometrial pathology:
| i.e. uterine septum, adhesions, polyp
39
What hormones should be tested for in an anovulatory cycle or infrequent periods?
- Urine HCG
- Prolactin
- TSH
- Testosterone and SHBG
- LH, FSH and oestradiol
40
How far apart should 2 semen analysis' be carried out?
twice over 6 weeks apart
41
What imaging modality can be used to visualise testicular cancer?
ultrasound
42
Describe how GnRH is released from the hypothalamus
Pulsatile release
43
Describe the difference in frequency of FSH and LH pulses
```
FSH = low frequency pulses
LH = high frequency pulses
```
44
How does FSH affect male and females differently?
FEMALES:
- Stimulates follicular development
- Thickens endometrium
MALE:
- Stimulates sertoli cells
- Spermatogenesis
45
Describe the difference in the effects of LH in a male and female
FEMALE:
- Peak stimulates ovulation
- Stimulates corpus luteum development
- Thickens endometrium
MALE:
- Stimulates Leydig cells
- Testosterone secretion
- Spermatogenesis
46
What phase of the menstrual cycle can be variable?
Follicular
47
What do ovulation test kits measure?
LH surge
| this usually occurs 36h before ovulation
48
Where is oestrogen secreted from?
ovaries - follicle
adrenal cortex
(placenta in pregnancy)
49
What structures secrete progesterone?
corpus luteum to maintain early pregnancy
| placenta during pregnancy
50
What effect does progesterone have on body temperature?
thermogenic effect => increases basal body temperature
51
How is oligomenorrrhoea described?
cycles >35 days
52
Describe the difference between Primary and Secondary Amenorrhoea
Primary - never had periods
| Secondary - had periods that have now stopped
53
How is a male with "no sperm" described?
azoospermia
54
What aspects of sperm are studied when assessing spermatogenesis?
Sperm Count
Sperm Motility
Sperm Morphology
55
How do the WHO classify causes of female infertility?
GROUP I - Hypothalamic pituitary failure
GROUP II - Hypothalamic pituitary dysfunction
GROUP III - Ovarian failure
56
What are the main causes of hypothalamic/pituitary failure?
- Stress
- Excessive exercise
- Anorexia / low BMI
- Tumours
- Head trauma
- Kallman’s syndrome
- Drugs (steroids, opiates)
57
What BMI should females aim for when attempting to conceive ?
18.5 > 30
58
What hormone therapies can be used to treat Group 1 of anovulatory disorders (Hypothalamic Pituitary failure)?
- Pulsatile GnRH
| - Gonadotrophin (FSH+LH) injections
59
What are the advantages of Pulsatile GnRH Treatment?
90% women ovulate
82% pregnant in a year
Multiple preg rate not significantly increased
60
What is the adverse effect of using FSH and LH injections?
higher multiple pregnancy rates
| => twins/triplets
61
What hormones are found to be abnormal in Group 2 - Hypothalamic pituitary dysfunction?
LH in excess
| GnRH and Oestrogen normal
62
What is the most common disorder which falls under Group 2 Hypothalamic Pituitary dysfunction
Polycystic Ovary Syndrome
63
Do most with Polycystic Ovary Syndrome present with Oligomenorrhoea or Amenorrhoea?
10-20% amenorrhoea
| 80-90% oligomenorrhoea
64
Describe the Rotterdam criteria used for diagnosis of Polycystic Ovary Syndrome?
- Oligo/Amenorrhoea
On ultrasound:
- >12 2-9mm follicles
- Increased ovarian volume
- Unilateral / bilateral
65
What is the pre-pregnancy treatment used in Polycystic Ovary Syndrome?
- 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
What drugs can be used for ovulation induction in PCOS?
- Clomifene Citrate (Clomid)
| alternatively Tamoxifen, Letrozole
67
What days of the cycle is Clomifene given to induce ovulation?
Days 2-6
68
Describe the mechanism of Clomifene and Tamoxifen
Prevents Oestrogen negative feedback
| => Stimulates GnRH and FSH/LH release
69
What injection can be given to stimulate ovulation in PCOS?
Gonadotrophin Injections
70
What are the advantages and disadvantages of Gonadotrophic Injections?
> Higher rates of ovulation and pregnancy than oral therapies
> Risk of multiple pregnancy
71
What therapy involves cautery to destroy parts of the ovary in the hope of inducing ovulation?
laparscopic ovarian diathermy
| used in PCOS
72
What percentage of PCOS patients become insulin resistant?
50-80%
73
What improvements can Metformin make in insulin resistant PCOS patients?
- Improves insulin resistance
- reduces androgen production
- Restoration of menstruation and ovulation
- May increase in pregnancy rate
- May improve sensitivity to clomifene
74
What are the main risks of ovulation induction?
- Ovarian hyperstimulation
- Multiple pregnancy
- Risk of ovarian cancer
75
What groups are at increased risk of ovarian hyperstimulation in induced ovulation?
If <35 years old
| PCOS Patients
76
If a mother experiences a multiple pregnancy (twins etc) what symptoms she at increased risk of?
Hyperemesis
Anaemia
Gestational Diabetes
Pre-eclampsia
77
If a mother experiences a multiple pregnancy (twins etc) what specific pregnancy complications she at increased risk of?
- miscarriage
- Low birth weight
- Prematurity
- Disability
- Stillbirth / neonatal death
- Twin-twin transfusion syndrome
78
What disabilities are most likely to be associated with twin births?
cerebral palsy
impaired sight
congenital heart disease
79
Describe the hormone profile of a patient with ovarian failure?
- High gonadotrophins
- Raised FSH
- Low oestrogen
80
What physiological situation is considered ovarian failure?/
Premature Menopause
| female runs out of eggs
81
What can cause premature ovarian failure?
- Genetic => Turner's/Fragile X
- Autoimmune ovarian failure
- Bilateral oophrectomy
- Pelvic radio/chemotherapy
82
What treatments are offered in premature ovarian failure?
- HRT
- Egg/Embryo donation
- cryopreservation prior to chemo/radiotherapy
83
What are the main causes of testicular failure?
- Klinefelters (47XXY)
- Y chromosome microdeletion
- undescended testes
- trauma / torsion / mumps
- cancer
- Pelvic radio/chemotherapy
- Autoimmune disease
84
What level of Prolactin indicates hyperprolactinaemia?
>1000 iu/l on 2 or more occasions
85
What class of drug is used to treat hyperprolactinaemia?
dopamine agonist
| e.g. cabergoline
86
If the sperm is injected int the egg for fertilisation, what is this process called?
Intracytoplasmic sperm injection (ICSI)
87
What procedure involves the introduction of sperm to the uterus artificially?
Intrauterine Insemination
88
If a baby was to present with rubella (due to mother not being vaccinated) what symptoms can be seen?
Widespread Rash
Microcephaly (brain)
Cataracts
Patent Ductus Arteriosus
89
What warning should be given when administering the rubella vaccine to females of child-bearing age?
Dont get pregnant within few months of getting the vaccine due to it being a LIVE formula
90
What treatments can be given for chlamydia infection?
Azithromycin
| Doxycycline (if macrolide allergy)
91
What clinical signs can indicate a potential diagnosis of PCOS?
Central obesity
Hirsutism
Acne
92
Male sperm count is declining. TRUE/FALSE?
TRUE
