Infertility Flashcards
What is infertility?
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 have not had a live birth previously
What is secondary infertility?
when have had a live birth >12 months previously
Infertility affects how many couples?
1 in 7
What impact does infertility have on the couple?
psychological distress, no biological child, impact on larger family, investigation, treatments often fail
What impact does infertility have on society?
less births, less tax income, investigation costs, treatment costs
Causes of infertility in males can be grouped into?
pre-testicular
testicular
post-testicular
List examples of pre-testicular causes of male infertility.
congenital/acquired endocrinopathies: Klinfelter’s 47XXY, Y chromosome deletion HPG, T, PRL
List examples of testicular causes of male infertility.
STDs, cryptorchidism, antisperm antibodies, varicocele, trauma/surgery, chemo/drugs/DXT/smoking
List examples of post-testicular causes of male infertility.
CF absence of vas deferens, obstructive azoospermia, erectile dysfunction (retrograde ejaculation, mechanical impairment, psychological), latrogenic (surgery)
Define cryptorchidism.
undescended testes from the abdomen to the scrotum
Define variocele.
mass of varicosed blood vessels in the testes
Causes of infertility in females can be grouped into?
pelvic tubal ovarian uterine cervical unexplained
List pelvic causes of infertility.
endometriosis
adhesions
List tubal causes of infertility.
tubopathy: infection, trauma, endometriosis
List ovarian causes of infertility.
anovulation
corpus luteum insufficiency
List uterine causes of infertility.
chronic endometritis (TB)
fibroid
adhesions
congenital malformation
List cervical causes of infertility.
antisperm antibodies
chronic cervicitis
What is endometriosis?
presence of functioning endometrial tissue outside the uterus (5% of women, responds to oestrogen)
Symptoms of endometriosis
more severe menstrual pain
menstrual irregularities
deep dyspareunia
infertility
Define dyspareunia.
painful intercourse
Treatments of endometriosis
hormonal (continuous OCP, prog)
laparoscopic ablation
hysterectomy
bilateral salpingo-oophorectomy
What is bilateral salpingo-oophorectomy?
removal of fallopian tubes and ovaries
What are fibroids?
benign tumours of the myometrium (1-20% of premenopausal women, ^ with age, responds to oestrogen)
What are symptoms of fibroids?
usually asymptomatic more severe menstrual pain Menstrual irregularities Deep dyspareunia Infertility
Treatment of fibroids
Hormonal (eg continuous OCP, prog, continuous GnRH agonists)
Hysterectomy
In hyperprolactinaemia, Kallman syndrome, what are the levels of gonadal axis hormones in males?
low GnRH
low LH
low FSH
low testosterone
In hypopituitarism, what are the levels of gonadal axis hormones in males?
low LH
low FSH
low testosterone
In congenital/acquired hypogonadism, what are the levels of gonadal axis hormones in males?
high LH
high FSH
low testosterone
What is Kallmann syndrome?
condition characterized by delayed or absent puberty and an impaired sense of smell (form of hypogonadotropic hypogonadism)
List reproductive features of Kallman syndrome.
Cryptorchidism
Failure of puberty: Lack of testicle dvlpt, micropenis, primary amenorrhoea
Infertility
Hyperprolactinaemia inhibits what neurons?
kisspeptin
List causes of hyperprolactinaemia.
Prolactinoma (micro/macro) Pituitary stalk compression Pregnancy & Breastfeeding Medications (Dop antagonists eg anti-emetics and antipsychotics) (Oestrogens eg OCP) PCOS Hypothyroidism
List examples of sex chromosome disorders.
Klinefelter syndrome XXY
Triple X syndrome XXX
Turner syndrome X0
Fragile X syndrome
List clinical features of Klinefelters syndrome.
tall stature, less facial/chest hair, mildly impaired IQ, narrow shoulder, gynecomastia, wide hips, low bone density, female type pubic hair pattern, small penis/testes, infertility
What information should you look for in initial history of a patient with potential male infertility?
duration previous children pubertal milestones associated symptoms medical/surgical/family/social history
What examinations should you carry out for a patient with potential male infertility?
BMI sexual characteristics testicular volume epididymal hardness presence of vas deferens other endocrine signs syndromic features anosmia
What main investigations should you carry out for a patient with potential male infertility?
semen analysis: vol, conc, motility
blood tests: LH/FSH/PRL, SHBG, albumin, karyotyping, morning fasting testosterone
microbiology: urine, chlamydia
imaging: MRI pituitary, scrotal US
What general lifestyle treatments are there for male infertility?
optimise BMI
smoking cessation
alcohol reduction/cessation
What specific treatments are there for male infertility?
dopamine agonist for hyperPRL
gonadotrophin for fertility
testosterone (for symptoms)
surgery (eg micro TESE)
In congenital/acquired hypogonadotrophic hypogonadism + hyperPRL, what are the levels of gonadal axis hormones in females?
low GnRH
low LH
low FSH
low E2
In hypopituitarism, what are the levels of gonadal axis hormones in females?
low LH
low FSH
low E2
In PCOS, what are the levels of gonadal axis hormones in females?
increased LH:FSH
normal/low E2
In hypergonadotrophic hypogonadism, what are the levels of gonadal axis hormones in females?
high LH
high FSH
low E2
What is the most common endocrine disorder and cause of infertility in women?
polycystic ovarian syndrome
What is the strategy for diagnosing PCOS?
exclude other reproductive disorders
2 out of 3 of Rotterdam Diagnostic Criteria
What are the Rotterdam PCOS diagnostic criteria?
oligo or anovulation
clinical/biochemical hyperandrogenism
polycystic ovaries (US)
How is oligo/anovulation usually assessed?
oligomenorrhoea <21d or >35, <8-9 cycles/y, > 90d for any cycle
anovulation can be proven by lack of progesterone rise or US
How is clinical hyperandrogenism usually assessed?
acne
hirsutism (Ferriman-Gallwey score)
alopecia (Ludwig score)
How is biochemical hyperandrogenism usually assessed?
raised androgens (eg testosterone)
How is polycystic ovaries assessed?
≥20 follicles OR ≥10ml either ovary on TVUS (8 MHz)
do not use US until 8 years post menarche
What are treatments for irregular menses/amenorrhea (PCOS)?
oral contraceptive pill
metformin
What are treatments for infertility (PCOS)?
clomiphene
letrozole
IVF
What are treatments for insulin resistance (PCOS)?
metformin
What are treatments for hirsutism (PCOS)?
antiandrogens
creams/waxing/laser
What are treatments for increased endometrial cancer risk (PCOS)?
progesterone courses
What are clinical features of Turner’s syndrome?
short stature low hairline webbed neck shield chest coarctation of aorta poor breast development/wide spaced nipples short 4th metacarpal elbow deformity underdeveloped reproductive tract amenorrhea brown nevi
What initial history should you get when investigating a patient with potential female infertility?
duration previous children pubertal milestones breastfeeding menstrual history medical/surgery/family/social history
What examinations should you carry out when investigating a patient with potential female infertility?
BMI sexual characteristics hyperandrogenism signs pelvic exam anosmia endocrine signs syndromic features
What main investigations should you carry out for a patient with potential female infertility?
blood test
pregnancy test
microbiology
imaging
What blood test should be carried out for a patient with potential female infertility?
LH FSH PRL oestradiol, androgens Foli phase 17OHP luteal prog SHBG albumin pituitary/thyroid profile karyotyping
What imaging should be carried out for a patient with potential female infertility?
US (transvaginal)
hysterosalpingogram
MRI pituitary (if low LH/FSH or high PRL)
