Infertility Flashcards
What is infertility?
A disease of the reproductive system defined by the failure to achieve a clinical pregnancy after ≥12 months of regular unprotected sexual intercourse
What is primary infertility?
When you have not had a live birth previously
What is secondary infertility?
When there has been a live birth in the past 12 months
What are the impacts of infertility on couples?
Psycological:
no child, family, treatement impact
What are the impacts of infertility on society?
Less births
Less tax income
Treatment costs
What are pre testicular causes of infertility in males?
Congenital or accquired eg Klinefeters, Y chromsome loss
What are testicular causes of infertility in males?
Congenital, STD/infections, immunological, vascular, trauma, toxins
What are post testicular causes of infertility in males?
Congenital, obstructive azoospermia, erectile dysfunction, latrogenic
What is cryptochidism?
Undescended testes (should be through inguinal canal)
What are causes of infertility in females?
Ovarian causes- anovulation, corpus luteum insufficiency
Tubal causes- tubopathy due to infection, trauma, endometriosis
Uterine causes- endometriosis, fibroid, adhesions
Cervical causes- ineffective sperm penetration sue to chronic cervicitis or immunological
What is endometriosis?
Presence of functioning endometrial tissue outside the uterus
(responds to oestrogen)
What are symptoms of endometriosis?
Menstrual pain
Pain on intercourse
Menstrual irregularities
Infertility
How is endomertriosis treated?
Hormonal
Laparascopic ablation
Hysterectomy
Bilateral Salpingo-oophorectomy
What are fibroids in infertile women?
Benign tumours of the myometrium
What are symptoms of fibroids?
Usually asymptomatic ↑ Menstrual pain Menstrual irregularities Deep dyspareunia Infertility
How are fibroids treated?
Hormones
Hysterectomy
What are LH, FSH and testosterone levels in a male with hyperprolactinemia?
LH-low
FSH-low
Testosterone-low
What are LH, FSH and testosterone levels in a male with Klinefelters (primary testicular failure)?
LH- high
FSH-high
Testosterone-low
What male infertility problems arise due to hypothalamus problems?
Congenital hypoganadotrophic hypogonadism (Kallmann syndrome)
Acquired hypoganadotrophic hypogonadism (low BMI, exercise, stress)
Hyperprolactinaemia
What are Gnrh, LH, FSH, testosterone levels in infertile males when the problem is in the hypothalamus?
All low
What male infertility problems arise due to anterior pituitary problems?
Hypopituitarism, tumour, Infiltration, Apoplexy, Surgery, Radiation
What are LH, FSH, testosterone levels in infertile males when the problem is in the hypothalamus?
All low
What male infertility problems arise due to gonad problems?
Klinefelters
Acquired primary hypogonadism (cryptorchidism, trauma, chemo, radiation)
What are LH, FSH, testosterone levels in infertile males when the problem is in the testes?
LH/FSH high
Testosterone low
What is Kallmann’s syndrome?
Failure of migration of GnRH neurons with olfactory fibres
How will Kallmann’s syndrome present?
Cryptorchidism Failure of puberty -Lack of testicle development -Micropenis -Primary amenorrhoea Infertility Anosmia
What hormone blocks kisspeptin neurones?
Prolactin
How does hypogonadism present?
Oligo or amenorrhoea /Low libido/ Infertility/Osteoporosis
What are the causes of hyperprolactinaemia?
Prolactinoma Pituitary stalk compression Pregnancy and breastfeeding Medications (dopamine antagonists) PCOS Hypothyroidism
What happens to sex chromosomes in Klinefelter’s?
Extra X chromosome (XXY)
How does Klinefelter’s present?
Tall stature Low facial and chest hair Breast development Small penis and testes Wide hips Low bone density Female like pubes Narrow shoulders
What should you include when taking history for an infertile man?
Duration, previous children, pubertal milestones, associated symptoms (eg. T deficiency, PRL symptoms, CHH features), medical & surgical history, family history, social history, medications/drugs
How should you examine an infertile man?
BMI, sexual characteristics, testicular volume, epididymal hardness, presence of vas deferens, other endocrine signs, syndromic features, anosmia
What are the main investigations for infertile males?
Semen analysis
Blood tests- LH, FSH, fasting testosterone, SHBG, albumin, iron, karyotyping
Microbiology- urine test, chlamydia swab
Imaging
What should male sperm vol be?
1.5 ml
What should sperm count be?
15 mill/ml
What should sperm motility be?
40%
What lifestyle changes are advised for infertile males?
Optimise BMI
Smoking cessation
Alcohol reduction/cessation
What treatment is available for infertile males?
Dopamine agonist for hyperprolactinemia
Gonadotrophin treatment for fertility (will also increase testosterone)
Testosterone
(for symptoms if no fertility required – as this requires gonadotrophins)
Surgery
Whats primary amenorrhea?
No period ever and >16 yrs old
Whats secondary amenorrhea?
Irregular periods, start but stop for 3-6 months
What would LH/FSH and oestradiol levels be in premature ovarian insufficiency?
LH-high
FSH-high
Oestradiol-low
What are symptoms of premature ovarian insufficiency (POI)?
Same as menopause
What are causes of POi
Autoimmune, genetic (fragile X or turners), cancer therapy
What would LH/FSH and oestradiol levels be in anorexia nervosa induced amenorrhea?
LH-low
FSH-low
Oestradiol-low
What are Gnrh, LH, FSH, oestradiol levels in infertile females when the problem arises due to the hypothalamus?
All low
What are LH, FSH, oestradiol levels in infertile females when the problem arises due to the anterior pituitary?
All low
What are LH, FSH, oestradiol levels in infertile females when the problem arises due to the ovary?
LH/FSH high
Oestradiol low
What is PCOS?
Most common cause of female infertility
How is PCOS diagnosed?
2/3 out of:
Oligo/anovulation- assessed by menstrual frequency
Hyperandrogenism- acne, hirtuism, alopecia, high testosterone
Polycystic ovaries
How is PCOS amenorrhea treated?
Oral contraceptive pill
Metformin
How is PCOS increased insulin resistance treated?
Metformin
How is PCOS hirtuism treated/
Creams/wax/laser, anti androgens
How does turners present and in what gender?
Females: Short Low hairline Wide spaced nipples Poor breast development Amenorrhea
How should you take a history for an infertile female?
Duration, previous children, pubertal milestones, breastfeeding,
Menstrual History: oligomenorrhoea or 1/20 amenorrhoea, associated symptoms, medical & surgical history, family history, social history, medications/drugs
How should you examine an infertile female?
BMI, sexual characteristics, hyperandrogenism signs, pelvic examination, other endocrine signs, syndromic features, anosmia
What are the main investigations for infertile females?
Blood test
Pregnancy test
Microbiology
Imaging
Describe the difference between Klinefelters, Kallmanns, Turner’s and fragile x syndrome
Klinefelter’s- congenital primary testicular failure, extra x chromosome
Kallmann’s- congenital hypogonadotrophic hypogonadism (due to problems in the pituitary)
Turner’s- congenital female condition where they are partially missing an x chromosome
Fragile X- congenital condition affecting x chromosome leading to developmental problems, intellectual disability etc
