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Genitourinary/Reproductive > Investigating infertility > Flashcards

Investigating infertility Flashcards

1
Q

define infertility

A

inability to conceive after 1-2 years
regular and unprotected sexual intercourse
in absence of any reproductive pathology

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2
Q

pregnancy rate after 1 years/ 2 years?

A

85%

92%

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3
Q

what’s primary/secondary infertility

A

primary: no pregnancies with livebirth (70%)
secondary: least one livebirth (30%)

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4
Q

biggest cause of infertility

A

35% male problems

35% tubal and pelvic pathology

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5
Q

what two things happen to oocytes as a woman ages?

A

loss of number

loss of quality

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6
Q

other factors affecting fertility

A

smoking
alcohol (W: 1-2 units/week, men 3-4 units/day)
Obesity (>30)
tight underwear
medication, recreational drugs (NSAIDs inhibit ovulation)

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7
Q

5 (female) reasons for infertility

A 
PCOS 
Hypogonadotrophic hypogonadism 
premature ovarian insufficiency 
hyperprolactinaemia 
hypo/hyperthyroidism
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8
Q

Rotterdam criteria for PCOS

A

2/3 of:

  • oligo/amenorrhoea
  • hyperandrogenism/hyperandrogenaemia
  • abnormal USS (12+ follicles per ovary and/or large volume >10mls)
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9
Q

describe PCOS aetiology

A

increased GnRH pulsatile frequency
increased LH
increased testosterone secretion
decreased SHBG (binds to testos)
arrest in folliculogenesis and ovulation = infertility
also increase in insulin –> more LH, insulin resistance

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10
Q

What are 4 other potential causes of exogenous testosterone increases that can mimic PCOS (and how do you test for them)?

A
  1. congenital adrenal hyperplasia (check other androgens: 17-OH progesterone, DHEAS, androstenedione)
  2. Cushing’s (synachten test)
  3. Androgen secreting tumour (USS)
  4. Steroid abuse (history)
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11
Q

Long term risks of PCOS

A

diabetes type 2
gestational diabetes
CVS and hypertension
endometrial hyperplasia and carcinoma

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12
Q

Investigations for PCOS

A

elevated free T and FAI (free androgen index)
pelvic USS

SHBG may be low
(+/- fasting glucose, triglycerides, other androgens)
pipelle endometrial biopsy if persistent thick endometrium elevated LH:FSH

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13
Q

Hypogonadotrophic hypogonadism

Symptoms

A

aka hypothalamic amenorrhoea
low FSH and low oetradiol
problem in the BRAIN

menopausal (hot flushes, vaginal dryness, mood changes)

Causes:
stress
pituitary surgery
inflammation (sarcoidosis, TB)
Sheehan’s (postpartum pituitary necrosis)
Congenital (Kallmann’s syndrome is GnRH absence)

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14
Q

Hypergonadotrophic hypogonadism

Symptoms

A

aka premature ovarian insufficiency
high FSH, high LH but low oestradiol (because of neg feedback, pituitary thinks needs to work harder so FSH is high)
problem is in the OVARY

Same menopausal symptoms

Idiopathic
Autoimmune (DM, thyroid dysfunction, pernicious anaemia)
Turner’s syndrome

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15
Q

Which cause of infertility may Kallmann’s syndrome be caused by?

A

Kallmann’s syndrome is GnRH absence.

Hypogonadotrophic hypogonadism

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16
Q

Signs/symptoms associated with hyperprolacinaemia

A

oligo/amenorrhoea
headaches
bitemporal hemianopia
galactorrhoea

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17
Q

what is diagnostic of hyperprolactinaemia

A

micro PRL

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18
Q

why does high levels of prolactin cause infertility

A

prolactin (produced by pituitary) inhibits LH and FSH release so that nothing stimulates the ovaries

usually prolactin is inhibited by dopamine

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19
Q

what is ‘moderate’ hyperprolactinaemia

A

1000-5000

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20
Q

what can thyroid dysfunction cause

A

anovulation
HMB (heavy menstrual bleeding)
miscarriage
stillbirth

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21
Q

what can cause tubal damage?

A

infection

  • PID, chlamydia trachomatis is primary pathogen
  • pelvic infection: appendicits, septic miscarriage, TB
  • Crohn’s
  • adhesions post C section
  • risk of ectopic surgery

Endometriosis
Hydrosalpinx - fluid is toxic to gametes/embryo

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22
Q

Uterine factors for infertility

A

fibroids (outgrowth of muscle, not cancerous - depends where it is to interfere with pregnancy. reduce area for implantation)
intrauterine adhesions
congenital anomalites

23
Q

if there’s a uterine anomaly, what must be done

A

renal USS

24
Q

Testicular dysfunction and failure of spermatogenesis caused by:

A 
testicular torsion 
cryptochidism 
infection (recent UTI, mumps) 
neoplasm, chemotherapy 
Klinefelter's 47 XXY
25
Q

Obstructive aetiology in the male

A

azoospermia
congenital: absence of vas deferens
iatrogenic: vasectomy
cystic fibrosis: bilateral vs. absence

26
Q

Varicocele

A

abnormally tortuous veins in spermatic cord

27
Q

Hypogonadotrophic hypogonadism in men

A 
Kallmann: 
absence of GnRH
low LH and testosterone 
insomnia 
failed puberty
28
Q

treat hypogonadotrophic hypogonadism for problems in infertility:
problems in puberty or libido:

A

fertility: GnRH pumps or LH and FSH

puberty or libido: give testosterone

29
Q

which drugs can cause erectile dysfunction

A

beta blockers

antidepressants

30
Q

why ask about post partum haemorrhage

A

can be cause of Sheenan’s

31
Q

why do we give folic acid

A

prevent neural tube defects eg. spina bifida

3 months pre conception for 12 weeks

32
Q

signs of endocrine disorder

A

acne, hirsutism: PCOS
virilization: CAH
visual field defects: pituitary tumour
goitre, exomphalom: thyroid disorder

33
Q

name the 7 investigations for female infertility

A
  1. reproductive hormones (day 1-5 early follicular phase)
  2. ovulation (mid-luteal progesterone. progesterone >30nmol is ovulatory)
  3. ovarian reserve/response to gonadotrophin stimulation
    (FSH >9 indicates poor response. also do Anti-Mullerian hormone test (low if running out of primordial follicles) low level = 5.4pmol)
  4. Transvaginal ultrasound scan (ovary, uterus, tubes)
  5. Hysterosalphingography (HSG) - check tubal patency and anatomy
    Laparoscopy and dye test
  6. Rubella immunity
  7. Chlamydia trachomatis
34
Q

azoospermia

A

no sperm

35
Q

oligoospermia

A

low sperm count

36
Q

tatrazoospermia

A

abnormal sperm morphology

37
Q

hypospermia

A

reduced volume

38
Q

normal FSH and testosterone

A

OBSTRUCTIVE

39
Q

low FSH and low testosterone

A

hypogonadotrophic hypogonadism (Kallmann’s)

40
Q

low FSH and high testosterone

A

anabolics

41
Q

high FSH and normal testosterone

A

failure of spermatogenesis (Kleinefelter’s)

42
Q

High FSH and low testosterone

A

complete testicular failure

43
Q

treatment of PCOS

A

clomiphene (anti-oestrogen, raises FSH, induces folliculogenesis) MONITOR blood or urinary oestrogen =does she grow a follicle (does she ovulate = progesterone)

then tamoxifen (SERM) or letrozole (aromatase inhibitor)

metformin

then gonadotrophin therapy (daily FSH till pre-ovulatory follicle. hCG not LH if no spontanous ovulation)

44
Q

managing hypothalamic amenorrhoea

A

increase weight
decrease exercise

faily FSH and hCG for ovulation
GnRH pulsatile administration

45
Q

management for hypogonadotrophic hypogonadism

A

no follicles, ovulation induction not possible. will not respond to gonadotrophins.

egg donation or adoption

46
Q

treatment for hyperprolactinaemia

A

dopamine agonists - BROMOCRIPTINE

transphenoidal pituitary surgery if macroadenoma >1cm

47
Q

treat hydrosalphinx

A

laparascopic salphingectomy, even if bilateral IVF

48
Q

how are adhesions uterine treated?

A

copper coil

49
Q

oligospermia/abnormal morphology/ poor moltility treat with what?

A

intracytoplasmic sperm injection (ICSI)

50
Q

if sperm problem is obstructive, how do we treat?

A

surgical sperm retrieval and intrauterine insemination

51
Q

treatment of male with hypogonagotrophic hypogonadism

A

gonadotropin therapy

52
Q

how do we do IVF?

A

downregulate GnRH with GnRH analogues (so we have control)
daily FSH given
frequent USS
hCG trigger when at least 3 follicles are >16mm
egg collection quickly 36-38hr from tirgger
semen collection
incubate sperm and oocyte overnight or ICSI
embryo transfer day 3 or 5

53
Q

IVF funding criteria Scotland

A 
3 cycles 
initiated <40 years 
turn 40 - can have 1 cycle 
female BMI between 19 and 30 
one partner no biological child 
both partners nonsmokers

Genitourinary/Reproductive (7 decks)

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