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Year 2 Endo > Infertility > Flashcards

Infertility Flashcards

1
Q

What is infertility?

A

A disease of the reproductive system defined by the failure to achieve a clinical pregnancy after ≥12 months of regular unprotected sexual intercourse.’

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2
Q

What is primary infertility?

A

When you have not had a live birth previously

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3
Q

What is secondary infertility?

A

When have had a live birth >12 months previously

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4
Q

Describe the epidemiology of infertility?

A

Affects 1 in 7 couples
But ~ half of these will then conceive in the next 12 months

55% will seek help positive association with socioeconomic status

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5
Q

What is the epidemiology of infertility? i.e which person %

A

Female 30%
Male 30%
Combined 30%
Unknown 10%

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6
Q

Why might infertility cause psychological distress to a couple?

A
  • No biological child
  • Impact on couples wellbeing
  • Impact on larger family
  • Investigations
  • Treatments (often fail)
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7
Q

What is the cost of infertility to the society?

A
  • Less births
  • Less tax income
  • Investigation costs
  • Treatment costs
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8
Q

What three types of causes of infertility in males?

A

Pre-testicular
Testicular
Post-testistcular

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9
Q

What is pre-testicular infertility?

A

Congenital & Acquired Endocrinopathies
Klinefelters 47XXY
Y chromosome deletion
HPG, T, PRL

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10
Q

What is testicular infertility?

A

(Congenital)

Cryptorchidism

Infection
STDs

Immunological
Antisperm Abs

Vascular
Varicocoele

Trauma/Surgery

Toxins Chemo/DXT/Drugs/Smoking

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11
Q

What is post-testicular infertility?

A

Congenital Absence of vas deferens in CF

Obstructive Azoospermia

Erectile Dysfunction Retrograde Ejaculation Mechanical Impairment Psychological

Iatrogenic Vasectomy

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12
Q

What is CRYPTORCHIDISM?

A

Undescended testis

90% in inguinal canal

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13
Q

What are the categories of causes in females?

A 
Ovarian causes
Tubal causes
Uterine causes 
Cervical causes
Pelvic causes
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14
Q

What are ovarian causes?

A

-Anovulation (Endo)
-Corpus luteum insufficiency
40%

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15
Q

What are tubal causes?

A

Tubopathy due:

  • Infection
  • Endometriosis
  • Trauma

30%

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16
Q

What are uterine causes?

A

Unfavourable endometrium due:

  • Chronic endometritis (TB)
  • Fibroid
  • Adhesions (Synechiae)
  • Congenital malformation
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17
Q

What are cervical causes?

A

Ineffective sperm penetration due:

  • Chronic cervicitis
  • Immunological (antisperm Ab)

5%

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18
Q

What are pelvic causes?

A
  • Endometriosis
  • Adhesions

5%

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19
Q

What is endometriosis?

A

Presence of functioning endometrial tissue outside the uterus

  • 5% of women
  • Responds to oestrogen
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20
Q

What are symptoms of endometriosis?

A

Increased Menstrual pain
Menstrual irregularities
Deep dyspareunia
Infertility

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21
Q

What are the treatments for endometriosis?

A

Hormonal (eg continuous OCP, prog)
Laparascopic ablation
Hysterectomy
Bilateral Salpingo-oophorectomy

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22
Q

What are fibroids?

A
  • 1-20% of pre-menopausal women (increases w age)

- Respond to oestrogen

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23
Q

What are symptoms of fibroids?

A 
Usually asymptomatic
Increased Menstrual pain
Menstrual irregularities
Deep dyspareunia
Infertility
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24
Q

What are treatments for fibroids?

A

Hormonal (eg continuous OCP, prog, continuous GnRH agonists)

Hysterectomy

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25
Q

What pattern of LH/FSH and testosterone would you see in hyper prolactinaemia?

A

All low

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26
Q

What pattern of LH/FSH and testosterone would you see in Klinefelters?

A

High FSH/LH

Low T

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27
Q

What can cause endocrine male infertility?

A

Androgen receptor deficiency (rare)

Hyper/hypothyrodism

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28
Q

What congential causes cause low GnRH?

A

Congenital Hypogonadotrophic Hypogonadism

-Anosmic (Kallmann Syndrome) or Normosmic

29
Q

What acquired causes cause low GnRH?

A

Acquired Hypogonadotrophic Hypogonadism

  • Low BMI, XS exercise, Stress
  • Hyperprolactinaemia
30
Q

What are the pituitary causes of Male infertility?

A

Hypopituitarism

-Tumour, Infiltration, Apoplexy, Surgery, Radiation

31
Q

What are the gonadal (affects testes, congenital & acquired) causes of male infertility?

A

Congenital Primary Hypogonadism
-Klinefelters (47XXY)

Acquired Primary Hypogonadism
-Cryptorchidism, Trauma, Chemo, Radiation

32
Q

What is Kallmann syndrome?

A

Failure of migration of GnRH neurones with olfactory fibres into the hypothalamus

Low GnRH
Low LH/FSH
Low T

33
Q

What are the symptoms of Kallmann syndrome?

A 
Cryptorchidism
Failure of puberty
-Lack of testicle dvlpt
-Micropenis
-Primary amenorrhoea
Infertility

Anosmia

34
Q

What does prolactin do to cause infertility?

A

Prolactin binds to receptors on kisspeptin neurons

Inhbits kisspeptin release

Decrease GnRH/LH/FSH/T/Oest

Oligomenhorrea/Amenorrhea/Low libido

35
Q

How do you treat hyperprolactinaemia?

A 
Dopamine agonist (Cabergoline)
Surgery/DXT
36
Q

What causes hyperprolactinaemia?

A

Prolactinoma (micro/macro)

Pituitary stalk compression

Pregnancy & Breastfeeding

Medications (Dop antagonists eg anti-emetics and antipsychotics) (Oestrogens eg OCP)

PCOS

Hypothyroidism

37
Q

What is Kleinfelter’s syndrome? And its’ effects on hormone levels

A

XXY

Increase LH and FSH
Low T

38
Q

What are the features/symptoms of Kleinfelters?

A 
Tall 
Low facial hair
Breast development
Female-type pubic hair
Small penis and testes
Infertility
Mildy impaired IQ
Narrow shoulders
Reduced chest hair
Wide hips
Low bone density
39
Q

What do you ask when talking an infertility history?

A 
duration
previous children
 pubertal milestones
associated symptoms (eg. T deficiency, PRL symptoms, CHH features)
medical & surgical history
family history
social history
medications/drugs
40
Q

What do you examine when looking at infertility? Which features?

A

including BMI, sexual characteristics, testicular volume, epididymal hardness, presence of vas deferens, other endocrine signs, syndromic features, anosmia

41
Q

What investigations (tests) can be conducted to determine cause of infertility?

A

Semen analysis
Blood tests (LH/FSH/PRL)
Micrbiology
Imaging

42
Q

What blood test are conducted? (male)

A

LH, FSH, PRL

Morning Fasting Testosterone

Sex Hormone Binding Globulin (SHBG)

Albumin, Iron studies

Also Pituitary/Thyroid profile

Karyotyping

43
Q

What is azoospermia?

A

No sperm

44
Q

What is oligospermia?

A

Reduced sperm

45
Q

What microbiology is conducted? (male)

A

Urine test

Chlamydia swab

46
Q

What imaging can be conducted to determine cause of male infertility?

A

Scrotal US/Doppler
(for varicocoele/obstruction, testicular volume)

MRI Pituitary
(if low LH/FSH or high PRL)

47
Q

What are the general lifestyle treatments for male infertility?

A

Optimise BMI

Smoking cessation

Alcohol reduction/cessation

48
Q

What are the specific treatments for male infertility?

A

Dopamine agonist for hyperPRL

Gonadotrophin treatment for fertility (will also increase testosterone)

Testosterone
(for symptoms if no fertility required – as this requires gonadotrophins)

Surgery
(eg. Micro Testicular Sperm Extraction (micro TESE))

49
Q

What is POI?

A

Premature Ovarian Insufficiency

50
Q

What are the symptoms of POI?

A

Same as menopause

51
Q

What causes POI?

A

Autoimmune
Genetic eg Fragile X Syndrome / Turner’s Syndrome
Cancer therapy Radio- / Chemo-therapy in the past

52
Q

What causes low GnRH in women? (congenital)

A

Congenital Hypogonadotrophic Hypogonadism

-Anosmic (Kallmann Syndrome) or Normosmic

53
Q

What causes low GnRH in women? (acquired)

A

Acquired
Hypogonadotrophic Hypogonadism

-Low BMI, XS exercise, Stress
Hyperprolactinaemia

54
Q

What are the pituitary causes of female infertility?

A

Tumour, Infilatration, Apoplexy, Surgery, Radiation

55
Q

What causes female infertility at the gonad level?(aquired)

A

PCOS

Premature Ovarian Insufficiency (POI)

-Surgery, Trauma, Chemo, Radiation

56
Q

What causes female infertility at the gonad level?(congenital)

A
  • Turners (45X0)

- Premature Ovarian Insufficiency (POI)

57
Q

What is PCOS? (epidemiology)

A

Affects 5-15% of women of reproductive age
Frequent family history
Most common endocrine disorder in women
Most common cause of infertility in women

58
Q

What is the Rotterdam PCOS diagnostic criteria?

A

2 out of 3

Oligo or Anovulation
Clinical +/- biochemical hyperandrogegism

Polycystic ovaries

59
Q

How do you assess menstrual frequency?

A

<21d or >35d cycles
<8-9 cycles/y
>90d for any cycle

60
Q

How do you assess hyperandrogenism?

A

CLINICAL
Acne, hirsutism (Ferriman-Gallwey score), alopecia (Ludwig score)

BIOCHEMICAL
Raised androgens (eg Testosterone)
61
Q

How do you assess cysts?

A

≥20 follicles OR ≥10ml either ovary on TVUS (8 MHz)

Do not use US until 8y post-menarche (due to high incidence of multi-follicular ovaries at this stage)

62
Q

What is the treatments for PCOS?

A 
Metformin 
Oral contraceptive pill
Anti-androgens
Creams, waxing, laser
Progesterone courses
63
Q

What are the symptoms of PCOS?

A 
Irregular menses
Infertility 
Increased insulin resistance
Impaired glucose homeostasis 
Hirtuism
Increased endometrial cancer risk
64
Q

What are the features of Turners?

A 
Short stature
Low hairline
shield chest
Wide-space nipples
Short 4th metacarpal
Small fingernails
Brown nevi
Characteristic faces
Webbed neck
Coarctation of aorta
Poor breast development
Elbow deformity
Underdeveloped reproductive tract
Amenorhea
65
Q

What do you ask in a fertility history? (female)

A

including duration, previous children, pubertal milestones, breastfeeding?,
Menstrual History: oligomenorrhoea or 1/20 amenorrhoea, associated symptoms (eg. E deficiency, PRL symptoms, CHH features), medical & surgical history, family history, social history, medications/drugs

66
Q

What is involved in a fertility examination? (female)

A

including BMI, sexual characteristics, hyperandrogenism signs, pelvic examination, other endocrine signs, syndromic features, anosmia

67
Q

What blood test are conducted? (female)

A

LH, FSH, PRL

Oestradiol, Androgens

Foll phase 17-OHP, Mid- Luteal Prog

Sex Hormone Binding Globulin (SHBG)

Albumin, Iron studies

Also Pituitary/Thyroid profile

Karyotyping

68
Q

What biochemical test are conducted (female infertility)?

A

Pregnancy Test
(urine or serum HCG

Urine test

Chlamidya swab

69
Q

What imaging is used to diagnose infertility in women?

A

US (transvaginal)

Hysterosalpingogram

MRI Pituitary
(if low LH/FSH or high PRL

Year 2 Endo (15 decks)

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