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Reproductive Health Block > Reproductive Endocrinology & Infertility > Flashcards

Reproductive Endocrinology & Infertility Flashcards

1
Q

Why is subfertility a better phrase to use than infertility?

A

Many of the barriers to conception are relative, rather than absolute, and in about 1/4 cases, no cause can be found.

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2
Q

When is a couple considered subfertile?

A

After they have tried to conceive for at least 12 months, not using any contraception, and having regular intercourse (every 2-3 days). The woman should be under 40 to maximise chances.

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3
Q

What is the background fertility rate of the general population?

A

80% within 1 year, 90% over 2 years.

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4
Q

Who do we need to investigate for fertilit issues?

A

Both partners

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5
Q

What are the main titles in causes of female infertility?

A 
Structural or endocrine:
Disorders of ovulation
Problem of tubes
Problem of uterus
Problem of cervix
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6
Q

What are the main titles in causes of male infertility?

A 
Structural or endocrine:
Disorders of testis and spermatogenesis
Disorders of genital tract
Disorders of ejaculation
Erectie dysfunction
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7
Q

How should we take a history from a woman with suspected subfertility?

A

Get an idea of general health and lifestyle, including BMI, smoking, drinking, recreational drugs, diet, and exercise.

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8
Q

Why is BMI important in female fertility?

A

A BMI below 19, or above 30 increases the risk of irrgular/an-ovulation, so chances of conception are much reduced.

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9
Q

Why is smoking important in female fertility?

A

Impairs fertility as well as increasing the risk of miscarriage, obstetric complications, IUGR, and may have long term effects on the child.

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10
Q

What is the link between fertility and:

a) cocaine?
b) cannabis?

A

a) cocaine can cause tubal infertility

b) cannabis can impair ovulation

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11
Q

When taking the sexual history in a case of subfertility, what 3 things do you need to cover?

A
  1. Frequency - ideally 2-3- times a week
  2. Prolonged/recureent absences of either partner
  3. Potential physical problems during intercourse e.g. dyspareunia, inadequate penetration
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12
Q

What previous medical treatments or conditions might result in impaired fertility?

A

Rx for malignancy (chemo)
Pelvic surgery or radiotherapy
Systemic disease, esp. those affecting the hypothalamic-pituitary axis.

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13
Q

What are the important signs to look for on examination of a woman with suspected subfertility?

A
  • Hirsutism
  • Acne
  • Pelvic mass
  • Signs of sexual difficulty e.g. vaginismus
  • Adnexal mass or tenderness
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14
Q

If a either member of a subfertile couple has had children before, what do you need to ask?

A
  • How many conceptions
  • How many for each partner, and how many together
  • Any previous problems of pregnancy, delivery, or post-partum
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15
Q

How many categories of disorders of ovulation does WHO describe?

A

4

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16
Q

What are type I ovulation disorders as categorised by WHO?

Give an example

A

Hypogonadal hypogonadism

Failure of pulsatile gonadotrophin secretion from pituitary.

Rare e.g. post surgery/radiotherapy for pituitary tumour

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17
Q

What are type II ovulation disorders as categorised by WHO?

Give an example

A

Normogonadotropic anovulation

Most common example is PCOS

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18
Q

What are type III ovulation disorders as categorised by WHO?

Give an example

A

Hypergonadotropic hypogonadism

Premature ovarian failure

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19
Q

What are type IV ovulation disorders as categorised by WHO?

Give an example

A

Hyperprolactinaemia with low/normal FSH & LH

Pituitary microadenoma

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20
Q

How do disorders of ovulation causing subfertility usually present?

A

Amenorrhoea or oligomenorrhoea

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21
Q

Why can tubal factors cause subfertility?

A

The ovum has to travel from the ovary to the uterine cavity, and be fertilised along the way.

If there is a physical barrier to either transport or fertilisation, the chances of conception are much lower.

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22
Q

What is the most common cause of tubal damage?

A

Infection.

If acute infection, it’s usually Chlamydia trachomatis.

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23
Q

How does the risk of tubal damage change with each episode of infection?

A

It roughly doubles each time:
After 1 episode, risk is 8%
After 2, risk is 16%
After 3, risk is 40%

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24
Q

What infection causing tubal damage is seen more and more commonly in the UK, especially in immigrant populations?

A

Uterine or tubal TB

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25
Q

What conditions, not obgyn, can cause external tubal damage -> subfertility?

How does this occur?

A

Appendicitis assoc. with peritonitis
Crohn’s disease/UC

Cause peritubal and periovarian adhesions.

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26
Q

What factor can cause tubal damage -> subfertility even in a patient with patent tubes?

A

Smoking -> decreased cilia motility

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27
Q

What is the major uterine factor causing subfertility?

A

Submucosal fibroids and congenital abnormalities

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28
Q

Why are uterine factors important in fertility?

A

Implantation is less likely to occur if the uterine cavity is distorted in some way.

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29
Q

What cervical factors may influence fertility?

A

Cervical muscus thickening secondary to infection or anti-sperm antibodies.
Cervical mucus is also hostile to sperm after ovulation.

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30
Q

How can we investigate a woman with fertility issues?

A

Assess ovulation depending on menstrual hx.

Investigate tubal patency.

Investigate cervical factors.

Investigate male partner.

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31
Q

How is ovulation assessed?

A

Detected with detection of LH surge approx. 24 hours before ovulation.

If ovulation not detected, Ix anovulation with FSH, LH, and oestradiol on day 2/3 of menstruation, serum prolactin and TFTs.

If serum prolactin is raised-> MRI/CT of sella turcica.

Can also visualise the ovaries with Ultrasonography, but this is time consuming.

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32
Q

What 3 methods can we use to investigate tubal patency?

A
  1. Hysterosalpingography
  2. Hysterosonocontrast sonography
  3. Laparoscopy and dye insufflation
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33
Q

Why do cervical factors not need to be investigated?

A

There is a lack of established normal criteria.

Modern treatments such as IVF and IU insemination bypass the cervix anyway.

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34
Q

What is the most useful investigation of male fertility?

A

Semen analysis

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35
Q

What factors are assessed in semen analysis?

A 
Volume
Sperm cell count
Motility
Morphology
Liquefaction time
WBC count in sample
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36
Q

What might low volumes of semen per ejaculate indicate?

What is a low level?

A

Androgen deficiency

Under 1ml

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37
Q

What might high volumes of semen per ejaculate indicate?

How much is too high a volume?

A

Abnormal accessory gland function

Over 4 ml.

38
Q

What kind of sperm count is associated with subfertility?

A

Abnormally high i.e. over 200 million/mL

39
Q

How many sperm should be mobile for a sample to be normal?

A

60% should have normal motility within one hour

40
Q

What endocrine assessments should be made in a subfertile male?

A

FSH
AMH
LH
Prolactin

41
Q

What is ovarian hyperstimulation syndrome, and what is it a complication of?

A

Increased release of oestrogens an progesterones as well as other vasoactive substances, causing increased membrane permeability so fluid moves from intravascular compartment.

It’s a complication of IVF, usually caused by gonadotropin or hCG treatment.

42
Q

What is ovarian reserve testing?

A

Different tests designed to measure the likely ovarian response to gonadotrophin stimulation in IVF.

43
Q

What are the 3 ways we can do ovarian reserve testing?

A
  • Total antral follicle count
  • Anti-Mullerian hormone
  • FSH

Measure around day 3 of menstrual cycle.

44
Q

What do we need to do for subfertility in a more holistic sense?

A

Support and reassure the couple.
Stress and pressure can adversely affect relationships and further contribute to fertility issues.

Fertility support groups may be helpful to the couple.

45
Q

What lifestyle measures can we suggest to help with subfertility?

A
  • Take folic acid in anticipation of pregnancy
  • Regular/frequent sexual intercourse
  • Alcohol - don’t drink over the recommended limit, and don’t drink when pregnant.
  • Reduce/quit smoking
  • Ideal BMI is between 19 and 30 - adjust to account for this.
  • Can plan intercourse around cycle, but little evidence of effectiveness.
46
Q

If the male in the partnership is subfertile due to abnormal sperm counts, what management options are there?

A
  • If obstructive cause, surgical correction may be helpful.
  • Lifestyle - can inform men that high scrotal temperature can reduce semen quality, but there is little evidence if wearing loose-fitting underwear will help.
47
Q

If the male in the partnership is subfertile due to disorders of genital tract, what management options are there?

A
  • Offer gonadotrophins if hypogonadotrophic hypogonadism.

- Depending on disorder, surger may be appropriate.

48
Q

When a woman is subfertile due to hypogonadal hypogonadism/hypothalamic amenorrhoea (Type I ovulation disorders), what Rx can we offer them?

A
  • Lifestlye changes (weight, exercise etc)
  • Pulsatile administration of gonadotrophin-releasing hormone or gonadotrophins with leutenising hormine to induce ovulation.
49
Q

What is PCOS?

A

Polycystic ovary syndrome is a condition characterised by polycystic ovaries and systemic symptoms causing reproductive, metabolic, and psychological disturbances.

50
Q

How does PCOS most commonly present?

A

With a combination of infertility, amenorrhoea, acne, and/or hirsuitism.

51
Q

Do all women with polycystic ovaries have PCOS?

A

No - up to a third of women of reproductive age may have polycystic ovaries, but not PCOS.

52
Q

How common is PCOS?

A

Thought to affect around 5-15% of women of reproductive age

53
Q

What are the 4 essential changes in PCOS?

A
  1. Excess androgens
  2. Insulin resistance
  3. Raised LH levels
  4. Raised oestrogen levels
54
Q

When do most patients with PCOS present?

A

Peri-pubertal period and through mid-20s

55
Q

What are the symptoms of PCOS?

A 
Oligomenorrhoea
In/subfertility
Acne
Hirsutism
Alopecia
Obesity/trouble losing weight
Sleep apnoea
Psychological symptoms.
56
Q

What are the signs of PCOS?

A

Hirsutism
Alopecia/male-pattern balding
Obesity
Acanthosis nigricans

57
Q

How is PCOS diagnosed?

A

2 out of 3 of Rotterdam criteria providing other causes have been excluded.

58
Q

What are the Rotterdam criteria?

A
  1. Polycystic ovaries (12+ peripheral follicles or ovarian vol over 10cm^3)
  2. Oligo-ovulation/anovulation
  3. Clinical/biochemical signs of hyperandrogenism
59
Q

A pt presents with oligomenorrhoea and subfertility. What are the differentials?

A

PCOS

Thyroid disorder
Hyperprolactinaemia
Cushing's
Acromegaly
Androgen-secreting ovarian or adrenal tumours
60
Q

A pt presents with oligomenorrhoea and subfertility. What Ix should be done for our top differential?

A

Bloods - Total testosterone, SHBG, LH, others indicated by presentation e.g. thyroid hormoes.
USS ovaries.
Fasting lipids and fasting glucose/OGTT.

61
Q

What are the aspects to managing PCOS?

A

Lifestyle changes

Medical management depending on if woman wishes to conceive

62
Q

How can PCOS be managed with lifestyle changes?

A

Weight control
Exercise
Low GI diet

63
Q

Why is PCOS associated with increased cardiovascular disease risk?

A

Associated with obesity, dyslipidaemia and insulin resistance

64
Q

With which cancer is PCOS associated?

A

Endometrial

65
Q

Why is PCOS associated with endometrial cancer?

A

Oligomenorrhoea and amenorrhoea combined with high oestrogen levels cause endometrial hyperplasia which predisposes to endometrial cancer.

66
Q

How can we prevent endometrial hyperplasia in women with PCOS?

A

COCP or cyclical progestogen, or IUS.

67
Q

Is PCOS managed or cured?

A

Managed - treat the symptoms.

68
Q

How is PCOS managed in women who are not planning pregnancy?

A 
COCP for menstrual irregularity
Metformin for insulin resistance
Co-cyprindrol for acne and hirsutism
Eflornithin for hirsutism
Orlistat for weight loss.
69
Q

How is PCOS managed in women who are planning pregnancy?

A

Clomifene induces ovulation, metformin improves pregnancy rates, and laparoscopic ovarian drilling or gonadotrophins if clomifene resistant.

70
Q

How common is infertility in PCOS?

A

PCOS is the cause of 75% of women who are infertile due to anovulation.

71
Q

What are the complications associated with PCOS?

A

Infertility is the big one. Endometrial hyperplasia and cancer, increased cardiovascular risk factors, increased risk of type 2 diabetes, sleep apnoea. Complications associated with pregnancy.

72
Q

What are the complications of PCOS associated with pregnancy?

A

Higher risk of gestational diabetes, preterm birth, and pre-eclampsia.

73
Q

What is precocious puberty?

A

The appearance of signs of pubertal development at an abnormally early age.

74
Q

What age is considered abnormally early for puberty in a girl?

A

Before age 8

75
Q

What age is considered abnormally early for puberty in a boy?

A

Before age 9

76
Q

Is precocious puberty more likely to be pathological in girls or boys?

A

Boys - in girls it’s often a benign central process.

77
Q

Is precocious puberty more common in boys or girls?

A

Girls - 5-10:1

78
Q

Do afro-caribbean or caucasian girls enter puberty earlier?

A

Afro-caribbean

79
Q

What social factor is thought to be contributing to earlier puberty?

A

Obesity

80
Q

How can precocious puberty be classified?

A

Gonadotrophin-dependant or central, and gonadotrophin-independent or precocious pseudopuberty.

Benign variants also occur.

81
Q

What is the pathophysiology of central precocious puberty?

A

Premature activation of hypothalamic-pituitary-gonadal axis usually idiopathic or due to CNS abnormality

82
Q

What CNS abnormalities can cause precocious puberty?

A

Tumours
CNS trauma or injury
Hamartomas
Congenital hydrocephalus or arachnoid cysts.

83
Q

What is the pathophysiology of pseudoprecocious puberty?

A

Appearance of secondary sexual characteristics due to increased production of female or male hormones occuring independantly of HPG axis.

84
Q

What can cause gonadotrophin-independent precocious puberty?

A

Congenital adrenal hyperplasia
HCG-secreting tumours
Other rare genetic syndromes
Testotoxicosis (AD familial male precocious puberty).

85
Q

What benign forms of precocious puberty are there?

A

Non-progressive (stabilises then regresses)

Isolated precocious thelarche/pubarche/menarche.

86
Q

How does precocious puberty present?

A

Normal pubertal development occurs earlier than expected or compared to school peers.

87
Q

What in a hx for precocious puberty might make you suspect central pathology?

A

Headaches
Visual changes
Seizures

88
Q

What elements of a history are important to get when faced with a child with ?precocious puberty?

A

CNS symptoms, age and rate of changes, family history, and growth history ideally plotted on a chart.

89
Q

How should precocious puberty be assessed O/E?

A

Height and weight (growth chart), Tanner stage, testicular volume, CNS examination, check for specific causes.

90
Q

What extra step should be done in boys when assessing precocious puberty?

A

Measure testicular volume

91
Q

How does testicular volume change in different types of precocious puberty?

A

It increases with normal puberty and central precocious puberty, but remains prepubertal in most causes of peripheral precocious puberty.

Reproductive Health Block (10 decks)

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