Infertility Flashcards
What is the definition of 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 the defintion of regular intercourse?
Every 2-3 days
What is primary infertility?
when have not had a live birth previously (e.g miscarriage)
What is secondary infertility?
when have had a live birth >12 months previously
How many people are affected by infertility?
•Affects 1 in 7 couples (= 14% of couples)
But ~ half of these will then conceive in the next 12 months (ie at 24months ~ 7% of couples
•55% will seek help (UK data)
•Positive association with socioeconomic status
What is the psychological distress impact to the couple?
- No biological child
- Impact on couples wellbeing
- Impact on larger family
- Investigations
- Treatments (often fail)
What is the cost to society on the couple?
- Less births
- Less tax income
- Investigation costs
- Treatment costs
What are the pre-testicular causes of infertility in men?
- Congenital + Acquired Endocrinopathies
1. Klinefelters 47XXY
2. Y chromosome deletion
3. HPG, T, PRL
What are the testicular causes of infertility in men?
- (Congenital)
- Cryptorchidism
- Infection: STDs
- Immunological: Antisperm Antibodies
- Vascular: varicocoele
- Trauma/Surgery
- Toxins: Chemo/DXT/Drugs/Smoking
What are the post testicular causes of infertility?
- Congenital: Absence of vas deferens in CF
- Obstructive Azoospermia
- Erectile Dysfunction: Retrograde Ejaculation, Mechanical Impairment, Psychological
- Iatrogenic: Vasectomy
What are undescended testes?
90% in inguinal canal
What are infertility causes in women?
- Uterine causes (10%)
- Tubal Causes (30%)
- Ovarian Causes (40%)
- Ineffective sperm penetration
- Unexplained (10%)
- Pelvic causes (5%)
What are some uterine causes for infertility?
- Unfavourable endometrium due:
1. Chronic endometritis (TB)
2. Fibroid
3. Adhesions (Synechiae)
4. Congenital malformation
What are some tubal causes of infertility?
- Tubopathy due:
1. Infection
2. Endometriosis
3. Trauma
What are some ovarian causes of infertility?
- Anovulation (Endo)
2. Corpus luteum insufficiency
When might there be ineffective sperm penetration and infertility?
- Chronic cervicitis
2. Immunological (antisperm Ab)
What pelvic causes can cause infertility?
- Endometriosis
2. Adhesions
What is endometriosis? What does it respond to?
- Presence of functioning endometrial tissue outside the uterus
- 5% of women
- Responds to oestrogen therefore symptoms
What are the symptoms of endometriosis?
- ↑ Menstrual pain
- Menstrual irregularities
- Deep dyspareunia
- Infertility
What are the treatments of endometriosis?
- Hormonal (eg continuous OCP, prog)
- Laparascopic ablation
- Hysterectomy
- Bilateral Salpingo-oophorectomy
What are fibroids?
- Benign tumours of the myometrium
- 1-20% of pre-menopausal women (increases w age)
- Respond to oestrogen so symptoms
What are the symptoms of fibroids?
- Usually asymptomatic
- ↑ Menstrual pain
- Menstrual irregularities
- Deep dyspareunia
- Infertility
What are the treatments of fibroids?
- Hormonal (eg continuous OCP, prog, continuous GnRH agonists)
- Hysterectomy
What are the reproductive features of Kallmann syndrome?
- Cryptorchidism
- Failure of puberty
- Lack of testicle dvlpt
- Micropenis
- Primary amenorrhoea - Infertility
- Anosmia
What are the symptoms of Kallmann syndrome?
- Olfactory placode (primitive nose)
2. Failure of migration of GnRH neurons with olfactory fibres (to hypothalamus)
What are the levels like in Kallmann syndrome?
- Low GnRH (not measurable)
- Low LH and low FSH
- Low testosterone
(hypogonadotrophic and hypogondasim)
What happens in hyperprolactinaemia?
- Prolactin binds to prolactin receptors on kisspeptin neurons in hypothalamus
- Inhibits kisspeptin release
- Decreases downstream GnRH/LH/FSH/T/Oest
- Oligo (>35d menses) or amenorrhoea (3-6m no menses)/Low libido (and other hypogonadal symptoms)/infertility/osteoporosis
What is the treatment of hyperprolactinaemia?
- Dopamine agonist (Cabergoline)
2. Surgery/DXT
What are the causes of hyperprolactinaemia?
- Prolactinoma (micro/macro)
- Pituitary stalk compression
- Pregnancy and Breastfeeding
- Medications (Dop antagonists eg anti-emetics and antipsychotics) (Oestrogens eg OCP)
- PCOS
- Hypothyroidism
What are sex chromosome disorder with infertility for men?
- XXY klinefelter syndrome 1-2/1000 births
- XYY syndrome
What are sex chromosome disorder with infertility for women?
- XXX triple X syndrome
- X0 Turner syndrome
- Fragile X syndrome
What are the symptoms of klinefelter syndrome?
- Tall sature
- Decreased facial hair
- Breast development
- Female type pubic pattern
- Small penis and testes
- Infertility (accounts for up to 3% of cases)
- Mildly impaired iQ
- Narrow shoulders
- Reduced chest hair
- Wide hips
- Low bone density
What are the levels like in Klinefelter syndrome?
- High LH and FSH (hypergonadotrophic)
2. Low T (hypogonadism)
What do you check for in the history for male infertility?
- including duration
- previous children
- pubertal milestones
- associated symptoms (eg. T deficiency, PRL symptoms, CHH features)
- medical and surgical history
- family history
- social history
- medications/drugs
What examination do you do for male infertility?
- BMI
- sexual characteristics
- testicular volume
- epididymal hardness
- presence of vas deferens
- other endocrine signs
- syndromic features
- anosmia
What blood tests do you order for male infertility?
- LH, FSH, PRL
- Morning Fasting Testosterone
- Sex Hormone Binding Globulin (SHBG)
- Albumin, Iron studies
- Also Pituitary/Thyroid profile
- Karyotyping
What microbiology do you order for male infertility?
- Urine test
2. Chlamydia swab
What imaging do you do for male infertility?
- Scrotal US/Doppler
(for varicocoele/obstruction, testicular volume) - MRI Pituitary
(if low LH/FSH or high PRL)
What lifestyle is good to avoid male infertility?
- Optimise BMI
- Smoking cessation
- Alcohol reduction/cessation
What could be specific treatment for male infertility?
- 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))
What is the menstraul cycle?
- 28-day cycle (24-35 days)
- ±2 days each month
What is primary amenorrhoea?
Later than 16yrs is regarded as abnormal
What is secondary amenorrhoea?
- Common for Periods to be irregular / anovulatory for first 18months.
- Periods start but then stop for at at least 3-6 months
What is Amenorrhoea?
No periods for at least 3-6 months -or up to 3 periods per year.
What is olgiomenorrhoea?
Irregular or Infrequent periods >35day cycles - or 4-9 cycles per year
What are the symptoms of premature ovarian insufficiency (POI)?
Same Symptoms as per Menopause
Can conception happen with POI?
In 20%
What is the diagnosis of POI?
High FSH >25 iU/L (x2 at least 4wks apart)
What are the causes of POI?
- Autoimmune
- Genetic eg Fragile X Syndrome / Turner’s Syndrome
- Cancer therapy Radio- / Chemo-therapy in the past
Why is POS so important?
- Affects 5-15% of women of reproductive age, frequent family history
- Most common endocrine disorder in women
- Most common cause of infertility
What do you need to be diagnosed with POS?
Rotterdamn PCOS diagnostic criteria (2 out of 2)
What are the oligo/anovulation criteria?
-Normally assessed by menstrual frequency as oligomenorrhoea:
<21d or >35d cycles
<8-9 cycles/y
>90d for any cycle
-If necessary anovulation can be proven by:
Lack of progesterone rise or US
What are the Clinical +/- Biochemical Hyperandrogenism criteria?
-CLINICAL;
Acne, hirsutism (Ferriman-Gallwey score), alopecia (Ludwig score)
-BIOCHEMICAL;
Raised androgens (eg Testosterone)
What are the polycystic ovaries criteria?
- ≥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)
What is the treatment for POS for irregular menses/amenorrhoea?
- Oral contraceptive pill
- Metoformin
What is the treatment for POS for infertility?
- Clomiphene
- Letrozole
- IVF
What is the treatment for POS for insulin resistance/impaired glucose homeostasis (T2DM, gestational DM)?
- Diet and lifestyle
- Metformin
What is the treatment for hirsutism in POS?
- Anti-androgen (e.g. spironolactone)
- Creams, waxing laser
How do you treat the increase endometrial cancer risk (2-6) in POS?
Progesterone courses
What are the symptoms of Turners syndrome (45X0) ?
- Short stature
- Low hairline
- Shield chest
- Wide-Spaced nipples
- Short 4th metacarpal
- Brown nevi
- Small fingernails
- Amenorrhoea
- Undeveloped reproductive tract
- Elbow deformity
- Poor breast development
- Coarctation of aorta
- Webbed neck
- Characteristic facies
What history do you take for female infertility?
- 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/drug
What examination do you do for female infertility?
- including BMI
- sexual characteristics
- hyperandrogenism signs
- pelvic examination
- other endocrine signs
- syndromic features
- anosmia
What blood tests do you do for female infertility?
- 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
- Pregnancy (urine of serum HCG)
What microbiology tests do you do in female infertility?
- Urine test
- Chlamydia swab
What imaging do you do for female infertility?
- US (transvaginal)
- Hysterosalpingogram
- MRI Pituitary
(if low LH/FSH or high PRL)
What are the levels like in primary testicular failure?
LH/FSH up, T down
What happens if there is a problem in the hypothalamus for endocrine male infertility?
- Low GNRH
- Low LH/FSH/T
- Hypogonadtrophic
- Hypogonadism
What is an example of congenital hypogonadotrophic hypogonadism for male/female infertility at hypothalamus leve?
Anosmic (can’t smell) (Kallman Syndrome) or Normosmic
What is an example of acquired hypogonadotrophic hypogonadism for male/female infertility at hypothalamus level?
- Low BMI
- Excess exercise
- Stress
What other condition is hypogonadotrophic hypogonadism for male/female infertility at hypothalamus level??
Hyperprolactinaemia (as prolactin will act with kisspeptin and shut down axis)
What are hypopituitary causes of endocrine male/female infertility?
- Tumour
- Infiltration
- Apoplexy
- Surgery
- Radiation
What will the levels be in hypopituitary causes of endocrine male/female infertility?
Low LH/FSH/T or E2
What is congenital primary hypogonadism that leafs to endocrine male infertility?
Klinefelters (47XXY)
What is congenital primary hypogonadism that leads to endocrine male infertility?
- Cryptorchidism
- Trauma
- Chemo
- Radiation
What are the levels like in primary hypogonadism?
- High LH/FSH
- Low T/E2 (depending on sex)
- Hypergonadotrophic hypogonadism
What are some other causes for endocrine male infertility?
- Androgen receptor deficiency (rare)
2. Hyper/hypothyroidism (reduced bioavailable testosterone) - same in women just oestridol not tetsosterpme
What should the results be for a semen analysis?
- volume: 1.5ml
- Sperm conc: 15million/ml
- Total motility: 40%
What levels do you see in premature ovarian insufficency?
- LH, FSH up
- Oestradiol down
What could cause female infertility acquired primary hypogonadism at gonad?
- POI
- Surgery, trauma, chemo radiation
What could cause female infertility congenital primary hypogonadism at gonad?
- Turners
- POI
What other condition could cause female infertility at gonad?
PCOS
What are levels like in PCOS?
- Decreased LH:FSH
2. Normal or decreased E2
What is the worst metabolic risk for POS?
Oligo/anovulation and clinical/biochemical hyperandrogism
What are the levels like in turners?
High LH/FSH and low T
