Subfertility Flashcards
infertility is defined as failure to achieve a clinical pregnancy after how long?
12 months
define primary infertility
infertility occurring in a couple who have never previously conceived
define secondary infertility
infertility occurring in a couple who have previously conceived
NB this includes pregnancies that did not result in a live birth e.g ectopic/miscarriage
where does spermatogenesis occur?
the seminiferous tubules
where in the male reproductive system does storage and maturation of sperm occur?
epididymis
spermatozoa pass from the ______ to the ____ ______ to the _______ where it joins the ____ _______ to form the _______ _____
from the epididymis to the vas deferens to the bladder where it joins the seminal vesicle to form the ejaculatory duct
what is the function of the bulbourethral gland?
produces and releases fluid which lubricates the urethra and neutralises any acidity prior to ejaculation
what is the function of the seminal vesicle?
produces and releases the majority of seminal fluid (this contains fructose, prostaglandins and fibrinogens)
GnRH stimulates the ____ pituitary to release which two hormones?
anterior pituitary
- LH
- FSH
LH stimulates testosterone secretion from what cells?
Leydig cells
L for LH
L for Leydig
inhibin is released from what cells in males?
sertoli cells
causes for male factor infertility can be broken down into three categories, what are they?
idiopathic
obstructive
non-obstructive
give an example of an obstructive cause of male infertility
cystic fibrosis (obstruction/absence of vas deferens)
vasectomy
testicular tumour
what would LH, FSH and testosterone levels be like in obstructive male infertility
NORMAL
no endocrinological issue, only obstruction
give an example of a non-obstructive cause of male factor infertility
cryptorchidism
klinefelter’s
Y chromosome microdeletion
robertsonian translocation
infection eg mumps, STIs
testicular tumour (can alter testosterone levels)
endocrine e.g pituitary tumours, hypothalamic disorders, thyroid disorders, diabetes, congenital adrenal hyperplasia
globozoospermia
sexual abuse
steroid abuse
what is the karyotype in klinefelter’s syndrome?
47 XXY
extra X chromosome
what is the phenotype of klinefelter’s syndrome?
- slight developmental delay
- reduced facial hair
- poor muscle tone
- gynaecomastia
LH, FSH and testosterone levels will be high/low in pituitary and hypothalamic disorders
low
define cryptorchidism
one or both testes being undescended into the dependant part of the scrotal sac
NB testes usually descended ~6-9 months
why does cryptorchidism cause male factor infertility
undescended testes will not be at the ideal temperature for spermatogenesis (2-4 degrees C)
which babies are most at risk of cryptorchidism?
- premature babies (<37 weeks)
- low birth weight
- small for gestatinal age
what will LH, FSH and testosterone levels be like in non-obstructive infertility?
high LH and FSH
low testosterone
female factor infertility can be split into two categories, what are these?
anovulatory
tubal
conditions causing anovulatory infertility may originate in which three areas?
hypothalamus
pituitary gland
ovary
give an example of a hypothalamic cause of female factor infertility?
anorexia
bulimia
excessive exercise
give an example of a pituitary cause of female factor infertility
hyperprolactinaemia (high prolactin suppresses LH/FSH)
sheehan syndrome (post-partum hypopituitarism)
pituitary adenomas (cause anovulation)
give an example of an ovarian cause for female factor infertility
PCOS
premature ovarian failure
what triad of symptoms are present in PCOS?
anovulation
polycystic ovaries on USS
hyperandrogenism
what are features of hyperandrogenism?
weight gain
acne
hair loss
anovulation
why do people with PCOS not release an egg at the time of ovulation?
overproduction of oestrogen by the ovary to compensate for high testosterone levels
NB testosterone can also impair ovum quality
LH will be high/low, in PCOS
high
failure of the ovary to produce oestrogen and healthy ova earlier than normal is called…
premature ovarian failure
how does premature ovarian failure present?
hot flushes
night sweats
atrophic vaginitis
oligo/amenorrhoea
LH will be high/low, FSH will be high/low and oestradiol will be high/low in premature ovarian failure
high LH
high FSH
low oestradiol
give an infective cause of tubal disease
- pelvic inflammatory disease (PID)
- transperitoneal spread of infection eg appendicitis
- iatrogenic e.g after IUD insertion
give a non-infective cause of tubal disease
- endometriosis
- salpingitis isthmica nodosa (scarring of the fallopian tube)
- uterine polyps
- fibroids
what previous infections should be asked about in an infertility history?
previous: STIs pelvic inflammation mumps epididymo-orchitis
what environmental risk factors should be asked about in an infertility history?
previous:
radiotherapy exposure
pesticide exposure
excessive heat on the testes
first line investigations for infertility in women
- swab for chlamydia
- smear test (only if due)
- transvaginal USS
- midluteal progesterone (used to confirm ovulation)
- serum progesterone (if irregular menstrual cycles)
- serum LH/FSH (if irregular menstrual cycles)
first line investigations for infertility in men
semen sample for semen analysis
endocrine profile
first line investigation for tubal patency in patients with possible tubal disease or previous pelvic pathology
laparoscopy
first line investigation for tubal patency in patients with no known risk factors for tubal/pelvic disease
hysterosalpingogram
name a second-line investigation for infertility in a female
chromosome analysis eg if amenorrhoeic
hysteroscopy if suspected endometrial pathology
name a second-line investigation for infertility in a male
scrotal ultrasound if abnormality detected on scrotal USS
nationally eligible patients are offered up to __ cycles of assisted conception treatment
3
BMI of the female partner must be above ___ and below ___
above 18.5 and below 30
fresh cycles of treatment must be initiated by the date of the female partner’s __th birthday
40
what supplement should be taken in women conceiving through assisted conception methods before and during pregnancy?
folic acid
couples must have been co-habiting in a stable relationship for a minimum of __ years
2
what type of ACT is this?
directly placing the sperm inside the uterus to facilitate fertilisation at the time of ovulation
intrauterine insemination (IUI)
when would someone not be a candidate for IUI?
not ovulating
tubal disease
low quality sperm
which ACT is best for couples with sexual dysfunction disorders such as erectile dysfunction?
intrauterine insemination (IUI)
what type of ACT is this?
a number of sperm are placed into a petri dish with an oocyte. the successful sperm fertilises the ovum, creating a zygote.
IVF
what type of ACT is this?
one sperm cell is immobilised and injected directly into the cytoplasm of the oocyte.
intra-cytoplasmic sperm injection (ICSI)
what ACT is best for patients with severe male factor infertility?
ICSI as it bypasses stages of the sperm travelling to the ovum, undergoing capacitation etc
which ACT is best for tubal disease?
IVF
which ACT is best for unexplained infertility?
IVF
unexplained infertility is infertility that lasts >_ years without a known cause
2
1st and 2nd line ACT options for patients with anovulatory infertility
- ovulation induction
2. IVF
how is ovulation induction done (hint: there are 3 steps)
- GnRH injection to induce follicular development and thicken the uterus for implantation. it also stops the LH surge which prevents the egg being released too early
- USS to assess the ovary and endometrium to plan timing of step 3
- HCG injection to stimulate the final stage of maturation of the oocytes
embryo transfer occurs on day __
5
NB normally only 1 embryo is transferred
what causes ovarian hyperstimulation syndrome?
medications used for ovarian stimulation such as GnRH and HCG injections cause large numbers of follicles to grow -> HIGH oestradiol levels -> release of inflammatory markers -> fluid shift from within the blood vessels to the third compartment
name a symptom of ovarian hyperstimulation syndrome
abdominal distension (due to third spacing of fluid) nausea and vomiting
