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Endocrinology > Investigation to infertility > Flashcards

Investigation to infertility Flashcards

1
Q

What is NICE definition of infertility?

A

A couple is referred for clinical assessment for infertility if, after regular (every 2-3 days) sexual intercourse, they have not conceived in a year

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2
Q

What is primary and secondary infertility?

A

Primary- Couples who have never conceived

Secondary- Couples who have previously conceived

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3
Q

How is fertility affected by age?

A

Fertility decreases with age

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4
Q

State some risk factors of developing infertility

A
  • Age (spefically in women)
  • Obesity, anorexia/excessive exercise
  • alcohol, drugs, smoking and occupation exposure
  • ovulatory disorders
  • tubal damage e.g. infection, blocked fallopian tubes, endometriosis
  • low sperm count
  • endocrine disturbances
  • infertility (1:7)
  • 25% of couples have unexplained infertility
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5
Q

Describe effects of obesity on fertility

A

Fertility decreases as BMI increases. Shown to be true in both males and females

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6
Q

What needs to be investigated in suspected female infertility`?

A
  1. assess menstrual cycle
  2. other hormonal causes of infertility (hypothyroidisms and prolactinaemia)
  3. assessing ovarian reserve
  4. structural or other abnormalitites (chlamydia)
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7
Q

How is the menstrual cycle assessed in suspected inferitlities (female)?

A
  • Assess regular cycles occur (26-36 days) - indicative of ovulation
  • ovulation: mid-luteal phase progesterone (day 21)(>30nmol/L)
  • if there are irregular cycles then day 2-5 LH and FSH to rule out menopause/premature ovarian failure
  • Rule out pregnancies using hCG
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8
Q

What causes anovulation/oligovulation?

A
  • Hypothalamic pituitary dysfunction
  • hypogonadotrophic hypogonadism
  • ovarian failure
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9
Q

Biochemical features of the causes to anovulation/oligovulation?

A

Hypothalamic pituitary dysfunction
- abnormal gonadotrophins and normal E2 -PCOS

Hypogonadotrophic hypogonadism
- Low FSH, LH, E2, but normal prolactin

Ovarian failure
- High LH, FSH and low E2

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10
Q

Match the following

  1. Low FSH
  2. Low LH
  3. High FSH
  4. High LH
  5. Low E2
  6. High E2

A. Ovarian failure
B. Hypogonadotrophic hypogonadism
C.

A

A345
B125
C

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11
Q

What are some other hormonal causes of infertility in females? and how is it investigated

A

Hypothyroidism and prolactinaemia.

  • Thyroid disease investigated using a TFT
  • subclinical hypothyroidism occur in 0.88-11.3% of women with ovulation disorders, causing menstrual and ovulatory disturbance associated with infertility
  • prolactin will be measured when there is ovulation disorder, galactorrhoea, or suspected pituitary tumour/disorder
  • hyperprolactinaemia cause irregular menstruation and possible infertility
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12
Q

How is the overian reserved assessed in suspected infertilities?

A
  • antral follicle count <4, by transvaginal ultrasound scan
  • Serum AMH <5.4pmol/L
  • Day 3 FSH>8.9 IU/L
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13
Q

What is the trend of AFC count in relationship to age adn BMI?

A

AFC increases with age and significantly increase with BMI

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14
Q

What structural abnormalities can cause infertility in females? what investigation

A
  • Main is chlamydia
  • tubal disease cause 14% infertility in women. Tubal obstruction could be due to infection (chlamydia), surgery or endometriosis
  • tubal patency is tested by HSG laproscopy with dye
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15
Q

What is polycystic ovarian syndrome?

A
  • most common cause of anovulatory infertility
  • associated with hirsutism, other features of metabolic syndrom: hyperinsulinaemia, insulin resitance, dyslipidaemia
  • Not all PCOS have polycystic ovarias, not all paitents of ovarian cysts have PCOS
  • hyperandrogenaemia
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16
Q

Investigation to PCOS?

A
  • Serum testosterone high >5pmol/l

- SHBG used to calculate free androgen index

17
Q

Define infertility in males

A
  • low sperm count or quality

- azoospermia = impaired semen quality

18
Q

What causes azoospermia?

A

Primary testicular failure
Obstruction of the genital tract
Hypogonadotropic hypogonadism

19
Q

What is the primary test for infertility in males?

A

Semen analysis which includes sperm count, motility, volume, pH, viability and WBC.
- If abnormal then repeat in 3 months to confirm

20
Q

What are some follow up tests in the investigation of male infertility?

A

Rule out hypogonadotrophic hypogonadism

  • FSH to detect primary from secondary testicular failure and investigate azoospermia
  • testosterone
  • LH
  • oestradiol if gynaecomastia present
  • prolactin if pituitary disorder suspected
21
Q

What are some non-biochemical causes of infertility in men?

A

Chlamydia, drugs/alcohol abuse, infections (raised leucocytes), impotence/anejaculation

22
Q

Biochemical features of the azoospermia causes.

A

Hypogonadotrophic hypogonadism
- low FH, FSH, testosterone and failure of spermatogenesis

Primary testicular failure
- high FSH and LH, low testicular volume

Obstruction of genital tract
- normal FSH and normal testis size

23
Q

What are some causes of Primary testicular failure?

A

Cryptorchidism, chromosome disorders (kleinfelters), systemic disease, radio/chemotherapy
- But 66% are unknown

24
Q

How do you treat infertility in females?

A

First line- medication for lack of ovulation e.g. anti-oestrogen, clomifene.
2nd line: endometrial scarring, fallopian tube repair, laparoscopic ovarian drilling

25
Q

How does clomifene restore fertility?

A

Clomifene is a selective oestrogen receptor modulator, which blocks negative feedback of oestrogen on GnRH release. Stimulating ovulation via FSH production to induce follicle development in anovulatory infertility

26
Q

What is the success rate of clomifene? and drawbacks?

A

Clomifene has a 70% succession rate in achieving ovulation in anovulatory cycles.

  • only used for 6 cycles
  • fails more in higher BMI
27
Q

What is the treatment for infertility in males?

A

Dependent on cause

  • Primary testicular failure = testosterone replacement
  • hypogonadotrophic hypogonadism= treat using hCG or pulsatile GnRH therapies

Endocrinology (12 decks)

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