infertility lecture and tutorial Flashcards
1
Q
what is defined as infertility?
A
failure to achieve a clinical pregnancy after more than 12 months of regular unprotected sexual intercourse
2
Q
what condition is met with primary infertility?
A
not had a live birth previously
3
Q
which condition is met in secondary infertility?
A
have had a live birth >12 months previously
4
Q
what are the three types of infertility causes for a male?
A
pre-testicular
testicular
post-testicular
5
Q
Give 2 examples of congenital pre-testicular infertility causes
A
Klinefelters 47XXY
Y chromosome deletion
6
Q
give an example of acquired pre-testicular infertility
A
high prolactin
7
Q
give a congenital example of congenital testicular infertility
A
cryptorchidism
8
Q
Give 5 examples of acquired testicular infertility
A
- infection eg. STDs
- Immunological - antisperm antibodies
- vascular (varicocoele)
- trauma / surgery
- toxins eg. chemo, drugs, smoking
9
Q
Give an example of congenital post-testicular infertility?
A
absence of vas deferens in cystic fibrosis
10
Q
Give 3 examples of post-testicular infertility
A
obstruction
erectile dysfunction
vasectomy
11
Q
what is cryptorchidism?
A
undescended testis usually stuck in inguinal canal
12
Q
Give 2 examples of ovarian causes of infertility
A
anovulation
corpus luteum insufficiency
13
Q
Give 4 examples of uterine causes (unfavourable endometrium) of female infertility
A
chronic endometritis
fibroid
adhesions
congenital malformation
14
Q
Give 2 examples of cervical causes of female infertility ie. ineffective sperm penetration
A
chronic cervicitis
Immunological (antisperm antibody)
15
Q
give 3 causes of tubal causes of female infertility
A
infection
endometriosis
trauma
16
Q
give 2 examples of pelvic causes of infertility
A
endometriosis
adhesions
17
Q
what is endometriosis?
A
functioning endometrial tissue outside uterus
18
Q
what is the treatment for endometriosis?
A
oral contraceptive pill, progesterone
laparascopic ablation
hysterectomy
bilateral salpingo-oophorectomy
19
Q
do fibroids respond to oestrogen?
A
yes
20
Q
what is a fibroid?
A
benign tumours of myometrium
21
Q
menstrual pain, menstrual irregularities, deep dyspareunia and infertility are all symptoms of which two diseases?
A
endometriosis and fibroids
22
Q
what pattern of LH, FSH and testosterone would you see in hyperprolactinaemia in men?
A
LH down
FSH down
testosterone down
23
Q
what pattern of LH, FSH and testosterone would you see in primary testicular failure?
A
LH up
FSH up
testosterone down
24
Q
what is failure of GnRH secretion called?
A
hypogonadotrophic hypogonadism
25
what are the three causes of hypogonadotrophic hypogonadism in both males and females?
congenital eg. Kallmann syndrome (anosmic)
acquired due to low BMI and stress
hyperprolactinaemia
26
name 5 causes of hypopituitarism in males and females
tumour, infiltration, apoplexy, surgery, radiation
27
name 5 causes of hypergonadotrophic hypogonadism in males
```
klinefelters 47XXY (congenital)
trauma, chemo, radiation, cryptorchidism
```
28
list two rare causes of hypogonadism in men
androgen receptor deficiency
| hyper/hypothyroidism
29
kallmann syndrome is caused by what?
congenital defect of migration of GnRH neurons with olfactory fibres into the hypothalamus
30
what are the symptoms of kallmann syndrome
cryptorchidism
failure of puberty
infertility
no sense of smell
31
name causes of hyperprolactinaemia
- prolactinoma
- pituitary stalk compression stopping dopamine reaching pituitary
- pregnancy and breastfeeding
- antipsychotics and anti-emetics, oestrogens eg. oral contraceptive pill
- PCOS
- hypothyroidism
32
```
tall stature
reduced facial hair
breast development
female-type pubic hair pattern
small penis and testes
infertility
mildly impaired IQ
narrow shoulders
reduced chest hair
wide hips
low bone density
```
are symptoms of?
klinefelter's syndrome
33
What initial questions would you ask when taking a history for male infertility?
```
duration
previous children
pubertal milestones
associated symptoms
medical and surgical history
family history
social history
medications/drugs
```
34
What would you examine when someone presents with male infertility?
```
BMI
sexual characteristics
testicular volume
epididymal hardness
presence of vas deferens
other endocrine signs
anosmia
syndromic features
```
35
what does azospermia mean?
no sperm
36
what does oligospermia mean?
reduced sperm
37
which core investigations would you carry out when a male presents with infertility?
semen analysis, blood tests, microbiology, imaging
38
Which blood tests would you carry out for male infertility?
```
LH, FSH, PRL
morning fasting testosterone
sex hormone binding globulin (SHBG)
albumin, iron studies
pituitary/thyroid profile
karyotyping
```
39
which tests would you carry out in the microbiology department for male infertility?
urine test
| chlamydia swab
40
what imaging would you carry out for male infertility and why?
scrotal US/Doppler - check for varicocoele/obstruction, testicular volume
MRI pituitary - (if low LH/FSH, high prolactin)
41
Lifestyle treatment for male infertility includes?
optimise BMI
smoking cessation
alcohol reduction/ cessation
42
what specific treatment could be used for hyperprolactinaemia
dopamine agonist
43
what would be the treatment for fertility in men
gonadotrophins
44
what would be the treatment for infertility in men who don't require fertility
testosterone
45
what would be the treatment if fertility is needed but the sperm can't get out
micro testicular sperm extraction
46
what is primary amenorrhoea
no periods past 16 years
47
secondary amenorrhoea is what?
periods start then stop for at least 3-6 months
48
amenorrhoea is what?
no periods for at least 3-6 months or up to 3 periods a year
49
oligomenorrhoea is what?
irregular or infrequent periods >35 day cycles OR 4-9 cycles per year
50
what pattern would you see in premature ovarian insufficiency in terms of LH, FSH and oestradiol?
LH up FSH up oestradiol down
51
premature ovarian insufficiency is diagnosed by what level of FSH?
>25 iU/L
52
causes of premature ovarian failure?
```
autoimmune
genetic eg. fragile X syndrome, turners syndrome
cancer therapy (chemo or radiotherapy)
```
53
What pattern of FSH, LH and oestradiol would you see in anorexia nervosa induced amenorrhoea?
LH, FSH, oestradiol all down
54
name 3 causes of hypergonadotrophic hypogonadism in females
premature ovarian insufficiency
PCOS
congenital primary hypogonadism eg. Turners (45X0)
55
name an alternate cause of infertility in females?
hyper/hypogonadism
56
How many of the Rotterdam PCOS diagnostic criteria need to be met in order to be diagnosed with PCOS?
2 out of 3
57
what are the Rotterdam PCOS diagnostic criteria?
oligomenorrhoea or anovulation
clinical/biochemical hyperandrogenism
polycystic ovaries
58
what are clinical signs of hyperandrogenism in females?
acne, hirsutism, alopecia
59
Polycystic ovaries are classed by?
> or equal to 20 follicles or > or equal to 10ml either ovary
60
when should polycystic ovaries (US) not be used? why?
8 years post-menarche because many follicles are common during this time
61
what are the main 4 problems that women with PCOS face?
irregular menses/amenorrhoea --> infertility
Increased insulin resistance --> T2DM, gestational DM
Hirsutism
Increased endometrial cancer risk
62
what is the treatment for infertility in PCOS?
clomiphene
letrozole
IVF
63
what is the treatment for increased insulin resistance in PCOS?
metformin, diet and lifestyle
64
treatment for hirsutism in PCOS?
creams, waxing, laser, anti-androgens
65
what is the treatment for increased endometrial cancer risk in PCOS?
progesterone courses
66
what initial history would you take in a female presenting with infertility?
```
duration
previous children
pubertal milestones
breastfeeding?
menstrual history
associated symptoms
medical and surgical history
family history
social history
medications/drugs
```
67
what would you examine when a female presents with infertility?
```
BMI
sexual characteristics
hyperandrogenism signs
pelvic examination
other endocrine signs
syndromic features
anosmia
```
68
what main four investigations would you do in a female with infertility?
blood tests, pregnancy test, microbiology, imaging
69
which blood tests should you do on women with infertility?
```
LH, FSH, PRL
oestradiol, androgens
follicular phase 17-OHP, mid-luteal progesterone
sex hormone binding globulin (SHBG)
albumin, iron studies
pituitary/ thyroid profile
karyotyping
```
70
which imaging should you do on women with infertility?
US (transvaginal)
hysteroalpingogram
MRI pituitary
71
which microbiology tests should you do on a woman with infertility?
urine test
| chlamydia swab
72
what is Kallmann's syndrome caused by?
congenital failure of migration of GnRH neurons with olfactory fibres into the hypothalamus
73
These symptoms indicate what?
```
short stature
low hairline
shield chest
wide spaced nipples
short 4th metacarpal
small fingernails
brown nevi
webbed neck
coarctation of aorta
poor breast development
elbow deformity
underdeveloped reproductive tract
amenorrhoea
```
Turner's syndrome (45X0)
74
how does letrozole work?
Letrozole works to induce ovulation by blocking estrogen production, leading to increases in follicle-stimulating hormone (FSH) release
75
How does clomiphene work?
blocks oestrogen receptors in hypothlamus, this in turn triggers release of FSH from the anterior pituitary following alterations in GnRH pulsatility.
76
30 year old, BMI 19 kg/m2, amenorrhoea for 6/12, runs daily to help with stress at work, training for London Marathon.
Oestradiol <70pmol/L (undetectable)
LH 0.5 U/L (2 – 14)
FSH 0.8 U/L (1.5 – 10)
Prolactin 300mU/L (100 – 500)
what is the diagnosis?
secondary hypogonadism - female athlete triad
| physiological response to famine/excessive loss of weight in order to conserve energy.
77
30 year old, BMI 30kg/m2, has gained weight over last 3 years. Oligomenorrhoea for 1 year. Acne and hirsutism particularly problematic over the last year too.
Oestradiol 150pmol/L (50-800)
LH 6 U/L (2 – 14)
FSH 3 U/L (1.5 – 10)
Testosterone 3 nmol/L (<1.8)
what is the diagnosis and treatment?
PCOS
weight loss
progesterone because she does have an endometrium - increased cancer risk
anti-androgen - spironolactone for hirsutism
for fertility
- letrozole
- clomiphene - antagonist for estrogen receptors in hypothalamus. Increase pulsatility of GnRH and drive ovulation.
IVF
78
40 y old, BMI 24kg/m2, amenorrhoea for 6/12, previously regular periods, no acne, hirsutism, galactorrhoea.
Oestradiol <70pmol/L (undetectable)
LH 30 U/L (2 – 14)
FSH 24 U/L (1.5 – 10)
Prolactin 300mU/L (100 – 500)
what is the diagnosis and treatment?
premature ovarian insufficiency
- premature menopause (LH and FSH are high - trying to drive failing ovaries with no negative feedback)
79
30 yearold, BMI 24kg/m2. Amenorrhoea for 6/12. Previously regular periods. Galactorrhoea. Recent visual disturbance.
Oestradiol <70pmol/L (undetectable)
LH 0.5 U/L (2 – 14)
FSH 0.5 U/L (1.5 – 10)
Prolactin 30, 000mU/L (100 – 500)
what's the diagnosis? and treatment?
prolactinoma
dopamine receptor agonist: cabergoline
80
30 year old, BMI 24kg/m2. Regular periods.
Oestradiol 150pmol/L (50-800)
LH 3 U/L (2 – 14)
FSH 3 U/L (1.5 – 10)
Prolactin 300mU/L (100 – 500)
diagnosis and treatment?
male infertility (partner) or something mechanical - blockage in fallopian tubes eg. pelvic inflammatory disease
Investigate partner for sperm count - if that's normal, look at fallopian tubes. Hysterosalpingogram (dye test, mapping out the tubes and uterus).
