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Year2 Endo > Infertility I > Flashcards

Infertility I Flashcards

1
Q

What is infertility

A

Failure to achieve clinical pregnancy after =>12 months of regular unprotected sexual intercourse

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2
Q

What is primary infertility

A

When you haven’t had a live birth previously

miscarriage / stillborn counted here

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3
Q

What is secondary infertility

A

When you’ve had a live birth > 12 months previously

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4
Q

What are the most common causes of infertility in a couple

A

1) male infertility 30%
2) female infertility 30%
3) combined male and female infertility 30%
4) unknown
10%

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5
Q

What are the impacts of infertility to the coupe

A 
Psychological distress : 
No biological child 
Impact on mental wellbeing of couple and family 
Investigations are invasive 
treatments often fail
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6
Q

What are the impacts of infertility to society

A 
Less births ( less tax income dude kinda harsh) 
Investigation + treatment costs
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7
Q

What are the 3 stages that can cause of male infertility

3 ways to think about male infertility

A

1) Pretesticular
2) testicular
3) Post testicular

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8
Q

What causes Pre testicular infertility

A

Congenital and acquired endocrinopathies :
Can be split into endo causes and physical causes

Physical causes
1) Klinefelter’s
47XXYY
3) Chromosome deletion

Endo causes:
4) HPG (hypothatmauls pituitary axis, Testosterone, prolactin

These can be due to 1ary , 2ary or 3ary hypogonadism

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9
Q

What are the causes of testicular infertility

A

1) congenital
2) Cryptorchidism
2) infection ie STD
3) Immunological ( antisperm ABs)
4) Vascular ( varcocoele)
5) Trauma/ surgery ( ie Vasectomy)
6) Toxin ( Chemo , DXT, Drugs, Smoking

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10
Q

What are the causes post testicular infertility

A

1) congenital ( absence of vas deference in CF)
2) Obstructive Azoospermia
3) Erectile dysfunction ( retrograde ejaculation , mechanical impairment , psychological)
4) Iatrogenic ( vasectomy)

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11
Q

What is cryptorchidism

A 
Undescended testis (90% stuck in inguinal canal) 
normal path for testis descent through inguinal canal)
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12
Q

What are the 6 causes of female infertility and name some examples of each

6 ways to think about female infertility

A

Check pregnant or breastfeeding

1) Uterine causes ( 10% )
( unfavourable endometrium due to chronic endometritis (TB) , fibroid, adhesions ( synechiae, congenital malformation)
2) Tubal causes ( 30%)
( Tubopathy due to : infection , endometriosis , trauma)
3) Ovarian causes ( 40%)
( Anovulation ( endo problems) , Corpus luteum insufficiency)
4) Cervical causes 5%
( ineffective sperm penetration due to : chronic cervicitis , immunological ( antisperm Ab)
5) Pelvic causes 5%
( Endometriosis , adhesion issues)
6) unexplained 10%

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13
Q

What are the causes of uterine infertility

A

unfavourable endometrium due to chronic endometritis (TB) , fibroid, adhesions ( synechiae) , congenital malformation

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14
Q

What are the causes of tubular infertility

A

Tubopathy due to : infection , endometriosis , trauma

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15
Q

What are the causes of ovarian infertility

A

Anovulation ( endo problems) , Corpus luteum

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16
Q

What are the causes of Cervical infertility

A

ineffective sperm penetration due to : chronic cervicitis , immunological ( antisperm Ab

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17
Q

What are the causes of Pelvic infertility

A

Endometriosis , adhesion issues

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18
Q

What is endometriosis

A

Presence of function endometrial tissue outside the uterus most commonly in the :
- fallopian tube
- ovaries
- outer uterine surface
- cul de sac area
( 5% of women . This tissue will respond to oestrogen)

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19
Q

Symptoms of endometriosis

A

Increase menstrual pain + irregularities
Deep dyspareunia ( pain during intercourse)
Infertility

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20
Q

what are the Treatments for endometriosis

A

Hormonal ( continuous OCP , prog)
Laparoscopic ablation
Hysterectomy
Bilateral salpingo-oophorectomy

note OCP = oral contraceptive pill

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21
Q

What is fibroids

A

Benign tumour of the myometrium ( most commonly:

  • submucosal
  • pedunculated subseroal
  • subserosal
  • Intramural

occurs in 1-20% of pre menopausal woman ( increases with age)
Responds to oestrogen

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22
Q

Symptoms of fibroids

A

Usually asymptomatic
Increase menstrual pain + irregularities
Deep dyspareunia
infertility

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23
Q

Treatment for fibroids

A

Hormonal ( continuous OCP , prog , continuous GnRH agonists)

Hysterectomy

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24
Q

What is hypothalamic - pituitary gonadal axis

A

1) Kisspeptin released from neurons in hypothalamus
2) Stimulates the release of GnRH from GNRH neurons in hypothalamus
3) Acts on gonadotrophs ( in anterior pit)
4) Stimulates LH = FSH circulation into systemic circulation
5) Causes testosterone / oestrogen ( progesterone / activin / inhibin) release in gonads
6) Oestrogen ( aromatised from T in men ) and progesterone acts back on hypothalamus and gonadotrophs (

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25
Q

What is the rhythm of GnRH and LH

A

pulsatile

sex steroids have a diurnal rhythm

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26
Q

How does hyperthyroidism cause infertility in males

A

Increased SHBG –> drop in free testosterone

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27
Q

How does hypothyroidism cause infertility in males

A

Decreased testosterone secretion

28
Q

What is Kallmann’s syndrome

A

Condition that causes hypogonadotropic hypogonadism and impaired sense of smell. This is due to a lack of GnRH.

This comes from the failure of migration of GnRH neurons with olfactory fibres from the olfactory placode to the hypothalamus

( Note can occur in females just more rare)

29
Q

How does Kallmann’s syndrome effect different hormones

A 
low GnRH ( unmeasurable) 
Low LH/FSH ( hypo gonadotrophic) 
low T ( hypogonadism)
30
Q

What are the symptoms of kallmann’s syndrome

A

Anosmia ( loss / change of smell)
Reproductive features ie ( cryptorchidism, failure of puberty –> lack of testicle dvlpt, micropenis , primary amenorrhoea , infertility

31
Q

What does prolactin do to kisspeptin neurons

A

Inhibits them

32
Q

What is the mechanism of action of hyperprolactinaemia

A

1) Prolactin binds to kisspeptin neurons in hypo
2) inhibits kisspeptin release
3) Decreases downstream GnRH/LH/FSH/Oest
4) oligo or amenorrhea , low libido , infertility , osteoporosis

33
Q

What is the treatment for hyperprolactinaemia

A 
Dopamine agonists ( cabergoline) 
Surgery / DXT
34
Q

What is Klinefelter’s syndrome

A

Sex chromosome disorder where males are born with XXY

35
Q

Symptoms of Klinefelter’s

A

1) tall stature
2) Decreased facial hair
3) breast development
4) female type pubic hair pattern
5) small penis + testes
6) Infertility 3%
7) mildly impaired IQ
8) narrow shoulders
9) reduced chest hair
10) wide hips
12) Low bone density

symptoms are more sever if >3 X chromones are present ( ie 48 XXXY or 49XXXXY) due to trisomy

36
Q

what hormones are effected in klinefelter’s

A 
Increased FH/LSH ( hypergonadotropic)
Decreased testosterone ( hypogonadism)
37
Q

What 3 things would you look for to diagnose male infertility

A

1) history
2) Examination
3) investigation

38
Q

What would finding the history of a man with infertility entail?

A

1) Duration
2) Prev children
3) pubertal milestones
4) associated symptoms ( T deficiency , PRL symptoms , CHH features) (CHH = HGP axis features)
5) medical and surgical history
6) family + social history
7) med / drugs

39
Q

What would the examinations of a man with infertility entail?

A

BMI, sexual characteristics , testicular volume , epidydimal hardness, presence of vas , endocrine signs , syndromic features , anosmia

40
Q

What would the investigations of a man with infertility entail?

A

1) semen analysis
( take a volume of 1.5 ml. Should have 15 mill / ml sperm
azoospermia = no sperm
oligospermia = reduced sperm
total motility = 40%
2) blood tests ( FHS /LH/PRL , morning fasting test , sex hormone binding globulin ( SHBG) , albumin , iron studies , pt / thyroid profile , karyotyping
3) microbiology ( urine test , chlamydia swab
4) imaging
( scrotal Ultrasound/Doppler for varicocoele / obstruction , testicular volume , MRI of pit glan if low LH/FSH or high PRL

41
Q

Treatment for male infertility

A

1) lifestyle –> optimise BMI , stop smoking + drinking
2) Dopamine agonist for hyperPRL , gonadotropin treatment for fertility ( will increase test) , Test ( for symptoms if no fertility requires), Surgery ( micro testicular sperm extraction ( microTESE)

42
Q

How long is a menstrual cycle

A

28 days ( 24 - 35 –> +/- 2 days each month)

43
Q

What is primary amenorrhoea

A

Periods start later than 16yrs ( abnormal)

44
Q

What is 2ary amenorrhoea

A

Irregular periods ( start then stop for at least 3-6 months)

( Remember common for periods to be irregular for first 18 months_)

45
Q

What is amenorrhoea

A

absence or periods ( no periods for at least 3-6 months or up to 3 periods per year

46
Q

What is oligomenorrhoea –> few periods

A

Irregular or infrequient periods >35 day cycles ( 4-9 cycles per year)

47
Q

What is premature ovarian insufficiency ( POI)

what is it caused by and how is it diagnosed

A

Early menopause

same symptoms as menopause
diagnosed by high FSH > 25iU/L ( x2 at least 4 weeks apart)

causes:
autoimmune
genetic ( fragile X syndrom / turner’s syndrome , cancer therapy ( radio / chemo)

48
Q

What is polycystic ovarian syndrome

A

most common cause of infertility and endocrine disorder in women

49
Q

How do you diagnose PCOS

polycystic ovarian syndrome

A

Exclude all other reproductive disorders

must meet 2/3 Rotterdam PCOS diagnostic criteria

50
Q

What are the 3 PCOS rotterdam diagnostic criteria

A

1) Oligio / Anovulation ( normally assed by menstural freq 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

2) clinical +/- Biochemical hyperandrogenism
(CLINICAL
Acne, hirsutism (Ferriman-Gallwey score), alopecia (Ludwig score)

BIOCHEMICAL
Raised androgens (eg Testosterone))

1 +2 are the worst metabolic risk combination

3) Polycystic ovaries (UltraSound)

≥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)

51
Q

Treatments for PCOS

A

1) oral contraceptive pill
to treat can cause irregular menses / amenorrhoea and infertility ( can be treated via clomiphene , letrozole , IVF)

2) Metformin ( can lead to irregular period / amenorrhoea and infertility and increased insulin resistance causing impaired glucose homeostasis ( T2DM, gestational DM)
3) Diet and lifestyle
4) Anti - androgens ( ie spironolactone , creams , waxing and laser ) used to treat hirsutism
5) Oral contraceptives and progesterone courses can increase endometrial cancer risk

52
Q

What is turner’s syndrome and what are the effects on hormones

A

45 X0

high LH , FSH ( hypergonadotropic

Low test Hypogonadism

53
Q

Symptoms of turner’s syndrome

A 
Short stature 
low hairline 
shield chest 
wide spaces nipples 
short 4th metacarpal 
small fingernails 
brown nevi 
characteristic facies 
webbed neck 
coarctation of aorta
poor breast development 
elbow deformity 
underdeveloped reproductive tract
amenorrhoea
54
Q

What is Anorexia nervosa induced amenorrhea:

A

hypothalamic dysfunction due to weight loss

leads to low FH, LSH , E2

55
Q

What happens in history taking in women

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

56
Q

What happens in examination of infertile women

A

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

57
Q

What are the main investigations

A 
1) Blood tests (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

2) Pregnancy test ( urine or serum HCG)
3) Microbiology ( urine test and chlamydia swab)
4) imagining ( US (transvaginal)

Hysterosalpingogram

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

58
Q

What diseases in male infertility are associated with problems of the hypothalamus
and what does this due to hormones

A

1) Congenital Hypogonadotropic Hypogonadism
- -> Anomic ( kallmann syndrome) or Normosmic

2) Acquired hypogonadotropic hypogonadism
- -> low BMI, Xs exercise , stress

3) hyperprolactinaemia

(low GnRH unmeasurable , low LH, Low FSH , low testosterone)

59
Q

What diseases in male infertility are associated with problems of the pituitary
and what does this due to hormones

A

1) Hypopituitarism
2) Tumour , infiltration , apoplexy , surgery , radiation

( Low LH, FSH + low T)

60
Q

What diseases in male infertility are associated with problems of the gonads
and what does this due to hormones

A

1) Congenital primary hypogonadism ( Klinefelter’s 47XXY )
2) Acquired primary hypogonadism ( cryptorchidism , trauma , chemo , radiation )

High FH/LSH , Low T

61
Q

What are other causes of male infertility

A

Androgen receptor deficiency ( rare)

Hyper/hypothyroidism ( reduced bioavailable testosterone)

62
Q

What diseases in female infertility are associated with problems of the hypothalamus
and what does this due to hormones

A

1) Congenital Hypogonadotrophic Hypogonadism
- Anosmic (Kallmann Syndrome) or Normosmic

2) Acquired Hypogonadotrophic Hypogonadism
- Low BMI, XS exercise, Stress

2) Hyperprolactinaemia

low GnRH , low FH/LSH, low E2

63
Q

What diseases in female infertility are associated with problems of the pituitary
and what does this due to hormones

A

Hypopituitarism
-Tumour, Infilatration, Apoplexy, Surgery, Radiation

↓LH ↓FSH Hypogonadotrophic
↓E2

64
Q

What diseases in female infertility are associated with problems of the gonads
and what does this due to hormones

A

1) Polycystic Ovarian Syndrome (PCOS

2) Acquired Primary Hypogonadism
- Premature Ovarian Insufficiency (POI)
- Surgery, Trauma, Chemo, Radiation

3) Congenital Primary Hypogonadism
- Turners (45X0)
- Premature Ovarian Insufficiency (POI)

↑LH ↑FSH HYPERgonadotrophic
↓E2

65
Q

what are other causes of female infertility

A

Hyper/Hypothyroidism (reduced bioavailable oestradiol)

Year2 Endo (13 decks)

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