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Endocrinology > Infertility > Flashcards

Infertility Flashcards

1
Q

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

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2
Q

What is primary infertility?

A

when 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

Infertility affects how many couples?

A

1 in 7

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5
Q

What impact does infertility have on the couple?

A

psychological distress, no biological child, impact on larger family, investigation, treatments often fail

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6
Q

What impact does infertility have on society?

A

less births, less tax income, investigation costs, treatment costs

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7
Q

Causes of infertility in males can be grouped into?

A

pre-testicular
testicular
post-testicular

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8
Q

List examples of pre-testicular causes of male infertility.

A

congenital/acquired endocrinopathies: Klinfelter’s 47XXY, Y chromosome deletion HPG, T, PRL

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9
Q

List examples of testicular causes of male infertility.

A

STDs, cryptorchidism, antisperm antibodies, varicocele, trauma/surgery, chemo/drugs/DXT/smoking

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10
Q

List examples of post-testicular causes of male infertility.

A

CF absence of vas deferens, obstructive azoospermia, erectile dysfunction (retrograde ejaculation, mechanical impairment, psychological), latrogenic (surgery)

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11
Q

Define cryptorchidism.

A

undescended testes from the abdomen to the scrotum

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12
Q

Define variocele.

A

mass of varicosed blood vessels in the testes

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13
Q

Causes of infertility in females can be grouped into?

A 
pelvic
tubal
ovarian
uterine
cervical
unexplained
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14
Q

List pelvic causes of infertility.

A

endometriosis

adhesions

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15
Q

List tubal causes of infertility.

A

tubopathy: infection, trauma, endometriosis

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16
Q

List ovarian causes of infertility.

A

anovulation

corpus luteum insufficiency

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17
Q

List uterine causes of infertility.

A

chronic endometritis (TB)
fibroid
adhesions
congenital malformation

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18
Q

List cervical causes of infertility.

A

antisperm antibodies

chronic cervicitis

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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

Symptoms of endometriosis

A

more severe menstrual pain
menstrual irregularities
deep dyspareunia
infertility

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21
Q

Define dyspareunia.

A

painful intercourse

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22
Q

Treatments of endometriosis

A

hormonal (continuous OCP, prog)
laparoscopic ablation
hysterectomy
bilateral salpingo-oophorectomy

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23
Q

What is bilateral salpingo-oophorectomy?

A

removal of fallopian tubes and ovaries

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24
Q

What are fibroids?

A

benign tumours of the myometrium (1-20% of premenopausal women, ^ with age, responds to oestrogen)

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25
Q

What are symptoms of fibroids?

A 
usually asymptomatic
more severe menstrual pain
Menstrual irregularities
Deep dyspareunia
Infertility
26
Q

Treatment of fibroids

A

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

Hysterectomy

27
Q

In hyperprolactinaemia, Kallman syndrome, what are the levels of gonadal axis hormones in males?

A

low GnRH
low LH
low FSH
low testosterone

28
Q

In hypopituitarism, what are the levels of gonadal axis hormones in males?

A

low LH
low FSH
low testosterone

29
Q

In congenital/acquired hypogonadism, what are the levels of gonadal axis hormones in males?

A

high LH
high FSH
low testosterone

30
Q

What is Kallmann syndrome?

A

condition characterized by delayed or absent puberty and an impaired sense of smell (form of hypogonadotropic hypogonadism)

31
Q

List reproductive features of Kallman syndrome.

A

Cryptorchidism
Failure of puberty: Lack of testicle dvlpt, micropenis, primary amenorrhoea
Infertility

32
Q

Hyperprolactinaemia inhibits what neurons?

A

kisspeptin

33
Q

List causes of hyperprolactinaemia.

A 
Prolactinoma (micro/macro)
Pituitary stalk compression
Pregnancy & Breastfeeding
Medications (Dop antagonists eg anti-emetics and antipsychotics) (Oestrogens eg OCP)
PCOS
Hypothyroidism
34
Q

List examples of sex chromosome disorders.

A

Klinefelter syndrome XXY
Triple X syndrome XXX
Turner syndrome X0
Fragile X syndrome

35
Q

List clinical features of Klinefelters syndrome.

A

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

36
Q

What information should you look for in initial history of a patient with potential male infertility?

A 
duration
previous children
pubertal milestones
associated symptoms
medical/surgical/family/social history
37
Q

What examinations should you carry out for a patient with potential male infertility?

A 
BMI
sexual characteristics
testicular volume
epididymal hardness
presence of vas deferens
other endocrine signs
syndromic features
anosmia
38
Q

What main investigations should you carry out for a patient with potential male infertility?

A

semen analysis: vol, conc, motility
blood tests: LH/FSH/PRL, SHBG, albumin, karyotyping, morning fasting testosterone
microbiology: urine, chlamydia
imaging: MRI pituitary, scrotal US

39
Q

What general lifestyle treatments are there for male infertility?

A

optimise BMI
smoking cessation
alcohol reduction/cessation

40
Q

What specific treatments are there for male infertility?

A

dopamine agonist for hyperPRL
gonadotrophin for fertility
testosterone (for symptoms)
surgery (eg micro TESE)

41
Q

In congenital/acquired hypogonadotrophic hypogonadism + hyperPRL, what are the levels of gonadal axis hormones in females?

A

low GnRH
low LH
low FSH
low E2

42
Q

In hypopituitarism, what are the levels of gonadal axis hormones in females?

A

low LH
low FSH
low E2

43
Q

In PCOS, what are the levels of gonadal axis hormones in females?

A

increased LH:FSH

normal/low E2

44
Q

In hypergonadotrophic hypogonadism, what are the levels of gonadal axis hormones in females?

A

high LH
high FSH
low E2

45
Q

What is the most common endocrine disorder and cause of infertility in women?

A

polycystic ovarian syndrome

46
Q

What is the strategy for diagnosing PCOS?

A

exclude other reproductive disorders

2 out of 3 of Rotterdam Diagnostic Criteria

47
Q

What are the Rotterdam PCOS diagnostic criteria?

A

oligo or anovulation
clinical/biochemical hyperandrogenism
polycystic ovaries (US)

48
Q

How is oligo/anovulation usually assessed?

A

oligomenorrhoea <21d or >35, <8-9 cycles/y, > 90d for any cycle
anovulation can be proven by lack of progesterone rise or US

49
Q

How is clinical hyperandrogenism usually assessed?

A

acne
hirsutism (Ferriman-Gallwey score)
alopecia (Ludwig score)

50
Q

How is biochemical hyperandrogenism usually assessed?

A

raised androgens (eg testosterone)

51
Q

How is polycystic ovaries assessed?

A

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

do not use US until 8 years post menarche

52
Q

What are treatments for irregular menses/amenorrhea (PCOS)?

A

oral contraceptive pill

metformin

53
Q

What are treatments for infertility (PCOS)?

A

clomiphene
letrozole
IVF

54
Q

What are treatments for insulin resistance (PCOS)?

A

metformin

55
Q

What are treatments for hirsutism (PCOS)?

A

antiandrogens

creams/waxing/laser

56
Q

What are treatments for increased endometrial cancer risk (PCOS)?

A

progesterone courses

57
Q

What are clinical features of Turner’s syndrome?

A 
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
58
Q

What initial history should you get when investigating a patient with potential female infertility?

A 
duration
previous children
pubertal milestones
breastfeeding
menstrual history
medical/surgery/family/social history
59
Q

What examinations should you carry out when investigating a patient with potential female infertility?

A 
BMI
sexual characteristics
hyperandrogenism signs
pelvic exam
anosmia
endocrine signs
syndromic features
60
Q

What main investigations should you carry out for a patient with potential female infertility?

A

blood test
pregnancy test
microbiology
imaging

61
Q

What blood test should be carried out for a patient with potential female infertility?

A 
LH FSH PRL
oestradiol, androgens
Foli phase 17OHP luteal prog
SHBG
albumin
pituitary/thyroid profile
karyotyping
62
Q

What imaging should be carried out for a patient with potential female infertility?

A

US (transvaginal)
hysterosalpingogram
MRI pituitary (if low LH/FSH or high PRL)

Endocrinology (15 decks)

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