Module 5: Fertility Concepts and Pathology Flashcards
Fertility
-natural capability to produce offspring
Fecundity
-potential output of reproduction by an organism
-measured by number of gametes, seeds, etc
Total fertility rate
-refers to total number of children born or likely to be born to a woman in her lifetime
Birth rate
-total number of live births per 1000 in a population in a year or period
How many couples of reproductive age experience infertility
-8-12%
Where is infertility most prevalent
-in developed countries
Age-fertility decline
-affects both men and women
What gender does age-fertility decline begin earlier in
-women
Where do fertility rates tend to be higher
-in developing countries
-due to lack of access of contraceptives, poor maternity care, and generally lower levels of female education
Why do developed countries tend to have lower fertility rates
-due to lifestyle choices associated with economic affluence where mortality rates are low, birth control is easily accessible, and children often can be seen as economic drain
Global fertility rate
-2.5 children per woman
What country has the lowest fertility rate
-europe
What is europes fertility rate
-1.6 children per woman
What country has the highest fertility rate
-africa
What is africas fertility rate
-4.7 children per woman
Population dynamic in Canada recently
-decline in fertility
How has Canada’s population structure changed
-from a relatively young and growing population to an aging population
Clinical terminology of fertility
-defined as capacity to establish a clinical pregnancy within 12 months of regular and unprotected sexual intercourse
Clinical terminology of subfertility
-general term used to describe any form of reduced fertility with a prolonged time to acheive conception in a couple
Clinical terminology for infertility
-incapability to establish a clinical pregnancy after 12 months of regular and unprotected sexual intercourse
-often due to potentially treatable causes
Clinical terminology for sterility
-refers to complete incapability to conceive naturally
-ex. due to absence of gonads regardless of cause
Primary infertility
-refers to couples who have not become pregnant after a minimum of 1 year of sexual intercourse without using birth control methods
Secondary infertility
-refers to couples who have previously carried a pregnancy to term, but are now unable to conceive
Factors that influence infertility
-hormones
-gametes
-gonads
-reproductive ducts
-external genitalia
How do hormones determine fertility
-circulating levels of regulator hormones of the reproductive system
How do gametes determine fertility
-quantity and quality of oocytes in females and sperm in males
How do gonads determine fertility
-anatomy and function of ovaries or testes
How do reproductive ducts determine fertility
-anatomy and function of the reproductive ducts in male and female
How does the external genitalia determine fertility
-anatomy and function of the external genitalia
What is the process of diagnosing infertility
-medical history
-physical exam
Medical history
-allows doctors to identify previous factors that may have caused fertility issues, as well as current factors that may be contributing
-takes into account medical condition, previous injuries or surgeries, and behavioural factors such as smoking
Physical exam
-evaluates presence of structural abnormalities in external genitalia and reproductive tract
-blood analyses allows doctors to detect hormonal imbalances and other potential metabolic abnormalities
Factors considered during medical history check
-previous physical injuries
-previous infections
-current systemic diseases
-current hormonal conditions
-current lifestyle factors
-other serious conditions
Specific diagnostic tests for males
-semen analysis
-testicular biopsy
-imaging
Semen analysis
-used to detect sperm abnormalities such as azoospermia
Testicular biopsy
-used to determine unexplained male infertility and azoospermia
Imaging in males
-pelvic and scrotal ultrasound or MRI
Specific diagnostic tests for both males and females
-physical exam
-hormonal tests
-genetic testing
Hormonal tests specific hormones both male and female
-FSH
-testosterone or progesterone
Genetic testing
-to diagnose certain genetic disorders affecting fertility
Specific diagnostic tests in females
-imaging
Imaging in females
-generally a hysterosalpingography which is an x ray of uterus and fallopian tubes to check for abnormalities
Idiopathic infertility
-when clinicians are still unable to identify the cause of infertility
-treatment can still be given and a successful pregnancy might be achieved
Congenital disorders that can cause infertility
-turners syndrome
-klinefelter syndrome
Turners syndrome
-condition in which a female is partially or completely missing one of her X chromosomes
Turners syndrome symptoms
-short stature
-webbing of neck
-widely spaced nipples
-cardiac and renal abnormalities
-other hormonal imbalances among many other health issues
Klinefelter syndrome
-genetic disorder in which boys are born with an extra X chromosome
-can cause hypogonadism in males
Klinefelter syndrome symptoms
-small testes
-tall/slender build
-low testosterone
-karyotyping
Menopause
-the point at which a woman no longer has menstrual period
-ovaries have stopped producing most of their estrogen and releasing eggs
When does menopause usually occur
-14-55 years of age
Premenopause
-years from puberty to menopause
-also referred to as the reproductive life of a female
Final menstrual period (menopause)
-defined as one year of spontaneous missed periods without any abnormality or drugs that can alter menstrual cycles
Postmenopause
-stage which begins with the last menstrual period and continues for the rest of a womans life
Perimenopause
-starts before menopause and continues 12 months after it
-when the body begins to undergo several physical and hormonal changes
Premature menopause
-spontaneous cessation of menses before age 40
What can induce artificial menopause
-radiation therapy
-oophorectomy (surgical removal of ovaries)
Follicular pool
-the number of extra follicles available for maturation
Ovarian reserve
-the capacity of the ovaries to produce an oocyte capable of fertilization and pregnancy
What happens to the follicular pool and ovarian reserve with age
-both decline progressively
Hormonal changes related to menopause
-increased sensitivity to GnRH
-less suppression of FSH secretion
Increased sensitivity to GnRH
-continual loss of remaining follicles means there is a decrease in the production of gonadotropin surge inhibiting factor
-resulting in higher sensitivity of pituitary to GnRH and therefore a rise in LH
Less suppression of FSH secretion
-rise in FSH which is attrivuted to a decreased production of inhibin B and antimullerian hormone (AMH)
-increasing FSH levels accelerates process of selection and recruitment of dominant follicles
-this speeds up the loss of remaining follicles
Oxidative stress
-physiological imbalance in the production of reactive oxygen species (ROS)
Reactive oxygen species (ROS)
-natural byproducts of metabolism which cause cellular damage by oxidizing and altering cellular DNA
Lifestyle factors and oxidative stress
-oxidative stress can be significantly worsened by lifestyle choices such as unhealthy diet, sedentarism, and smoking etc
Fertility and oxidative stress
-considered to be a major factors in the process of natural fertility decline
When does the risk of experiencing pregnancy complications increase
-after the age of 35
When does age-related fertility decline start in men
-around 40 years of age
Andropause
-progressive hormone decline in males
-also known as late-onset hypogonadism
Andropause symptoms
-low sex drive
-lack of energy
-difficulty getting erections
-loss of muscle mass or strength
-increased body fat
-depression and/or mood swings
-hot flashes
What percent of men at age 40 are impacted by erectile dysfunction
-10%
What percent of men over the age of 70 are impacted by erectile dysfunction
-80%
What is one of the primary causes of erectile dysfunction on men over 50
-atherosclerotic disease
Other potential causes of erectile dysfunction
-psychological
-neurological
-hormonal
-pharmacological
-anatomical
What happens to serum testosterone levels with time
-decrease
What is the decrease of serum testosterone levels due to
-decrease in leydig cells
-deterioration of testicular perfusion
-disturbances to GnRH and chorionic gonadotropin secretion
Primary hypogonadism
-testosterone deficiency due to a testicular defect
Secondary hypogonadism
-testosterone deficiency caused by a problem with the pituitary gland or hypothalamus
-testes are normal but there is abnormal signaling from the brain
Sex hormone binding globulin (SHBG)
-a hormone that binds to testosterone in the blood and reduces the amount of available testosterone
Primary testicular failure
-decine in testosterone secretion caused by a deficiency or absence of leydig cell function
How is sperm affected with age
-volume, motility, and morphology are all decreased
Why are sperm affected with age
-often due to increase in replication errors, DNA mutations and fragmentation in sperm cells
Benign prostatic hyperplasia
-prostate enlargement in older men
What happens to semen volume after the age of 45
-gradually decreases due to functional decline of accessory glands
What are children born to older parents most at risk for
-down syndrome
Direct injury to genitals
-have potential to result in permanent impairment of function depending on severity
Which gender are direct injuries more common in
-males
Direct injuries in women
-not common
-can happen as a vaginal or uterine prolapse after childbirth
Indirect injury
-would involve an injury to a non-reproductive structure that ends up interfering with normal reproductive function
Example of indirect injury
-spinal cord injury
How can spinal cord injuries affect reproductive function
-loss of mobility in legs
-can affect innervation of reproductive organs
Parasympathetic innervation of male reproductive system
-parasympathetic nerves from S2-4 nerve roots primarily control erectile function by controlling arterial dilation
Sympathetic innervation of the male reproductive system
-sympathetic nerves from T11-L2 control detumescence and contribute to ejaculation and emission by controlling gland secretions and release of sperm
What is detumescence
-the subsidence of a swelling, especially the return of a swollen penis, to the flaccid state
What can SCI inflicted nerve damage lead to in males (impaired)
-reflecogenic erections
-psychogenic erections
Reflexogenic erections
-an erection which is stimiulated by direct stimulation of genital region
Psychogenic erections
-initiated by thoughts and erotic stimuli, independent of direct genital stimulation
What can happen to sperm production with SCI
-production and quality can decrease due to factors such as increased temperature due to prolonged sitting, decreased physical activity, and less frequent sperm discharge
Parasympathetic innervation of the female reproductive system
-parasympathetic nerves from S2-4 nerve roots control clitoral erection as well a relaxation of uterine smooth muscles
Sympathetic innervation of female reproductive system
-sympathetic nerves from T11-L2 control the contraction of the uterus
Somatic innervation of the female reproductive system
-derived from both T12-L2 and S2-S4 and provides pain perception
What is amenorrhea
-the absence of menstruation
-happens often to women after suffering a traumatic injury to the spine
Changes in sexual response in women after SCI
-decreased lubrication
Can women with an SCI still get pregnanct
-yes because sexual function is independent of reproductive function in women
Risks of pregnancy during SCI
-higher risk of preterm labour
-thrombosis or autonomic dysreflexia
-brachycardia
-excessive sweating and headaches
What is an infection that can have a major impact on reproductive function
-STI’s
What is the most common communicable disease that affects fertility
-chlamydia
Chlamydia effects in women
-can cause pelvic inflammatory disease
What is pelvic inflammatory disease
-infection that spreads to upper reproductive tract
-can result in injury and scarring of affected tissue
-can result in tubal factor infertility
Chlamydia effects in males
-can cause infections in urethra and epididymis
-associated with sperm damage via DNA fragmentation
What percent of poeple in canada have had HPV at some point
-70%
HPV symptoms
-asymptomatic
-genital warts
-cancer
Types of cancer that can be caused by HPV infection
-cervical cancer
-anal cancer
-oropharyngeal cancer
-rarer cancers such as vaginal, vulvar, and penile
Treatment options for HPV induced cancers
-surgery
-radiation therapy
-chemotherapy
-hormone therapy
Surgery for HPV induced cancer
-best approach
-depending on location can sometimes harm reproductive tissues and cause scarring
Radiation therapy for HPV induced cancers
-high energy radiation from x rays, gamma rays, neutrons, protons, etc
-can equally damage normal cells
-some organs can be protected such as ovaries with ovarian shielding
Chemotherapy for HPV induced cancer
-involves use of drugs to stop growth of cancerous cells
-can be toxic to normal cells, and can impair the function of gonads
Hormone therapy for HPV induced cancer
-can disrupt the menstrual cycle and the HPG axis
-this may then affect fertility
HPV prevention
-hygiene
-condom use
-vaccines
Vaccines for HPV
-can provide significant protection against becoming infected
-traditionally given to girls but now may be given to boys as well
Common chronic conditions associated with fertility
-hypertension
-type II diabetes
-cardiovascular disease
Diabetes effects in females
-alterations in length of menstrual cycle
-alterations in age of onset of menopause
What condition is common with insulin resistance
-PCOS
What does insulin act a under normal conditions in women
-gonadotropin in theca cells
Diabetes affects in males
-erectile dysfunction
-ejaculatory dysfunction
-higher percentage of sperm with nuclear and mitochondrial DNA fragmentation
-lower implantation rates
-early onset of childhood diseases
Diabetes induced autonomic neuropathy
-may be the cause of erectile and ejcaculatory dysfunction in men
Main lifestyle factor that may affect fertility
-nutrition
Malnutrition effect on fertility
-lacks nutrients to produce energy or maintain cellular processes
-affect fertility through disruption of hormones in the HPG axis
-food deprivation disrupts the GnRH pulse
Overnutrition effect on fertility
-can result in hyperlipidemia, hyperinsulemia etc
-this can increase androgen secretion and impact fertility
-can also have a negative impact on energy homeostasis by forcing body to compensate for excess nutritional intake
Impact of glucose on female fertility
-insulin resistance is strongly associated with PCOS
Impact of glucose on male fertility
-abnormal glucose homeostasis is believed to negatively affect sperm cell metabolism
-dysfunction in nutrient transport and decreased fertility
Other lifestyle factors that may affect fertility
-physical activity
-alchohol intake
-smoking habit
-drug use
-medication use
What is an assisted reproductive technology
-methods that help to treat subfertility
Assisted reproductive technology
-intrauterine insemination
-in vitro fertilization
-third part assisted ART
Intrauterine insemination
-insemination is acheived by using a catheter to deposit sperm directly into the uterine cavity as close to the fallopian tube as possible
In vitro fertilization
-eggs and sperm are incubated in a laboratory to produce a viable embryo
-the embryo is then transferred to the womans uterus
Third party assisted ART
-where someone other than the parents aids in reproduction
-surrogacy
-egg/sperm donation
Intrauterine insemination process
-may be combined with controlled ovarian hyperstimulation, where hormone injection is used to promote maturation of additional follicles
-this injection is timed around ovulation and sperm is deposited in fallopian tube before ovulation
Stages of in vitro fertilization
-ovarian stimulation
-egg retrieval
-sperm retrieval
-fertilization
-embryo transfer
IVF ovarian stimulation
-injected hormones are used to promote the maturation of more than follicle
IVF egg retrieval
-eggs are collected from the ovaries by inserting a hollow needle through the vaginal wall to access the ovary
IVF sperm retrieval
-male provides a semen sample that will be used in lab to combine with egg
-sperm are centrifuged to concentrate it and reduce volume of semen
IVF fertilization
-concentrated semen is placed in a petri dish with the egg and incubated overnight to fertilize
-if they do not fertilize on their own, fertilization if performed via intracytoplasmic sperm injection
IVF embryo transfer
-transferred to the uterus 1-6 days after fertilization, by using a long tube to inject it directly into the uterus
Types of third party assisted ART
-sperm donation
-embryo donation
-gestational surrogacy
-egg donation
-traditional surrogacy
Sperm donation
-can be used to perform IUI or IVF
Embryo donation
-used in cases when both partners are infertile
-embryos can be frozen for adoption
Gestational surrogacy
-similar to traditional but carrier is implanted with embryo that is not biologically related to her
Egg donation
-egg donor will undergo ovarian hyperstimulation and egg retreival, and donated eggs with me fertilized with IVF and placed in uterus
Traditional surrogacy
-when woman is infertile
-surrogate is inseminated with sperm from male partner, which will produce a child that is related to male partner and surrogate
