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Endocrinology > Infertility > Flashcards

Infertility Flashcards

1
Q

What is Infertility?

A

A disease of the reproductive system defined by the failure to achieve a clinical pregnancy after ≥12 months of regular unprotected sexual intercourse.’

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2
Q

What is primary infertility?

A

When they have not had a live birth …

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3
Q

What is secondary infertility?

A

When have had a live birth more than 12 months previously

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4
Q

Is it a male factor or female?

A

Combination

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5
Q

What psychological distress is caused?

A

No biological child

  • Impact on couples wellbeing
  • Impact on larger family
  • Investigations
  • Treatments (often fail)
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6
Q

How does infertility affect society?

A

Less births

  • Less tax income
  • Investigation costs
  • Treatment costs
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7
Q

What pre-testicular infertility causes are there?

A

Congenital & Acquired Endocrinopathies
Klinefelters 47XXY
Y chromosome deletion
HPG, T, PRL

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8
Q

What testicular infertility causes are there? 6

A

(Congenital)

Cryptorchidism

Infection STDs

Immunological Antisperm Abs

Vascular Varicocoele

Trauma/Surgery

Toxins
Chemo/DXT/Drugs/Smoking

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9
Q

What post testicular causes are there for infertility?

A

Congenital: - Absence of vas deferens in CF

Obstructive Azoospermia

Erectile Dysfunction Retrograde Ejaculation Mechanical Impairment Psychological

Iatrogenic Vasectomy

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10
Q

What is cryptorchidism?

A

Men:

Normal path down for testis descent is through inguinal canal sometimes this path remains undescended

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11
Q

What causes are there for female infertility?

A
  • Uterine causes
  • Tubal causes
  • Pelvic causes
  • Ovarian causes
  • Cervical causes
  • Unexplained
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12
Q

What Uterine causes are there for infertility?

A

Unfavourable endometrium due:

  • Chronic endometritis (TB)
  • Fibroid
  • Adhesions (Synechiae)
  • Congenital malformation
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13
Q

What tubal causes are there for infertility in women?

Make up for 30%

A

Tublopathy which can be due to:

  • Infection
  • Endometriosis
  • Trauma
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14
Q

What pelvic causes are there for infertility in women?

Make up for 5%

A
  • Endometriosis

- Adhesions

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15
Q

What cervical causes are there for infertility in women?

Make up for 5%

A

Ineffective sperm penetration due:

  • Chronic cervicitis
  • Immunological (antisperm Ab)
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16
Q

What ovarian causes are there for infertility in women?

Make up for 40%

A
  • Anovulation (endo)

- Corpus Luteum Insufficiency

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17
Q

What is Endometriosis?

A

Presence of functioning endometrial tissue outside the uterus

  • found in 5% of women
  • Responds to oestrogen
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18
Q

What are the symptoms of endometriosis?

A

↑ Menstrual pain

Menstrual irregularities

Deep dyspareunia

Infertility

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19
Q

What are the treatments for endometriosis?

A

Hormonal (eg continuous OCP, prog)

Laparascopic ablation

Hysterectomy

Bilateral Salpingo-oophorectomy

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20
Q

What is Fibroids and how does this cause infertility?

A

Benign tumours of the myometrium

1-20% of pre-menopausal women (increases w age)

-Responds to oestrogen

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21
Q

What are the symptoms of fibroids?

A

Usually asymptomatic

↑ Menstrual pain

Menstrual irregularities

Deep dyspareunia

Infertility

(similar symptoms as endometriosis)

22
Q

What are the treatments for fibroids?

A

Hormonal (eg continuous OCP, prog, continuous GnRH agonists)

Hysterectomy ( if in endometrium )

23
Q

What are the effects of congenital Hypogonadotrophic Hypogonadism

If Anosmic it is Kallmanns syndome (loss of smell is distinguishable factor)

Or

Normosmic hypogonadotrophic hypogonadism

A

Low GnRH
Low LH FSH
Low T

Not measurable

24
Q

What are the effects of Acquired Hypogonadotrophic Hypogonadism

-Low BMI, excessive exercise, Stress

A

Low LH FSH

Low T

25
Q

What can cause hypopituitarism in men and what affect does this have?

A 
Tumour
Infiltration
Apoplexy
Surgery
Radiation

Low LH FSH
Low T

26
Q

What is congenital primary hypogonadism and how does this affect serum levels?

A

Kleinefelters 47XXY

High LH FSH
Low T

27
Q

How can a man get acquired primary hypogonadism?

A
  • Cryptorchidism
  • Trauma
  • Chemo
  • Radiation

High LH FSH
Low T

28
Q

what rare diseases can cause male infertility?

A

Androgen receptor deficiency

29
Q

What is Kallmann syndrome and how does it affect smell

A

During embryo development GnRH neurones migrate from olfactory placode to hypothalamus, if there is GnRH migration it will also cause olfactory migration issue.

  • Anosmia
  • Cryptorchidism
  • Failure of puberty : lack of testicle development, micropenis, primary amenhorrhoea (in women), infertility
30
Q

What do we need dopamine agonist such as Cabergoline for?

A

Hyperprolactinaemia

  • slide 21
31
Q

What sex chromosome disorders are there?

A

males:
XXY - klinefelter
XYY syndrome

females:
XXX - triple X syndrome
X0 - Turner syndrome
Fragile X syndrome

32
Q

What physical manifestations occur in Klinefelters?

A 
Tall
Decreased facial hair
Breast development
Female type pubic hair pattern
Small penis + testes
Infertility
Wide hips
Low bone density
Reduced chest hair
Narrow shoulders
Mildly impaired IQ
  • symptoms are typically more severe if three or more X chromosomes are present * 48,XXXY, 49,XXXXY
33
Q

What to ask during a male infertility history?

A
  • including duration,
  • previous children,
  • pubertal milestones,
  • associated symptoms (eg. T deficiency, PRL symptoms, CHH features),
  • medical & surgical history, - family history,
  • social history, - medications/drugs
34
Q

What examinations to conduct on male infertility?

A
  • BMI
  • sexual characteristics
  • testicular volume
  • epididymal hardness
  • presence of vas deferens
  • other endo signs
  • anosimia
35
Q

What is a normal semen analysis:

A

1.5ml volume
15 mill/ml sperm concentration
40% Total motility

36
Q

What is azopermia and oligospermia?

A

azospermia = no sperm oligospermia = reduced sperm

37
Q

Which tests to do for male infertility?

A 
LH FSH PRL
Morning fast testosterone
Sex hormone binding globulin - SHBG
Albumin, iron studies
pituitary/thyroid profile
Karyotyping

*also do urine and chlamydia swab

38
Q

What imaging to do for male infertility?

A
  • Scrotal US/doppler for varicocoele/obstruction, testicular volume
  • MRI pituitary if low LH FSH or high PRL
39
Q

What treatment is offered for male infertility?

A

lifestyle : optimise BMI, smoking cessation, alcohol reduction/cessation

Specificly:

  • dopamine agonist for hyperPRL
  • Gonadotrophin treatment for fertility
  • Testosterone if no fertility is required
  • Surgery e.g. micro testicular sperm extraction
40
Q

What is POI and what can cause it?

A

Premature ovarian insufficiency

Same symptoms as menopause

Conception can happen in 20%

To diagnose find FSH is high >25 , do this twice atleast 4 weeks apart

Autoimmune, genetic or cancer therapy causes

41
Q

Which diseases can cause infertility in women with Low GnRH, Low LH FSH, low E2?

A
  • Congential hypogondotrophic hyogonadism
    : Anosmic (Kallmans) or normosmic
  • Acquired hypogonadotrophic hypogonadism - Low BMI, XS exercise, stress
  • HyperPRL
42
Q

Which diseases can cause just low LH FSH and Low E2?

A

Hypopiuitarism: tumour, infiltration, apoplexy, surgery, radiation

43
Q

Which diseases can cause high LH FSH normal or low E2?

A

PCOS - polycystic ovarian syndrome

44
Q

Which diseases can cause high LH FSH low E2?

A

Acquired primary hypogonadism, ( hypergonadotrophic )
POI

Congential primary hypogonadism e.g. turners, POI

45
Q

How is polycystic ovarian syndrome diagnosed?

A

Rotterdam PCOS diagnostic criteria

- oligo or anovulation:
Normally assessed by menstrual frequency as oligomenorrhoea:
<21d or >35d cycles
<8-9 cycles/y
>90d for any cycle

If necessary anovulation can be proven by:
Lack of progesterone rise or US

  • Clinical +/- biochemical hyperandrogenism:
    CLINICAL
    Acne, hirsutism (Ferriman-Gallwey score), alopecia (Ludwig score)
BIOCHEMICAL
Raised androgens (eg Testosterone)
  • Polycystic ovaries:
    ≥20 follicles OR ≥10ml either ovary on TVUS (8 MHz)

Do not use US until 8y post-menarche (due to high incidence of multi-follicular ovaries at this stage)

46
Q

How to treat PCOS ?

A

for irregular/amenorrhoea:
oral contraceptive pill

for insulin resistance increase:
metformin

for hirsutism: creams,waxing,laser.
anti-androgens

47
Q

what are the physical manifestations of turners syndrome?

A 
short
low hairline
shield chest
wide spaced nipples
short 4th metacarpel
small fingernails
brown nevi
amenorrhoea
Underdeveloped reproductive tract
elbow deformity
poor breast development
coarctation of aorta
webbed neck
c
48
Q

How to take a history for female infertility?

A

including duration, previous children, pubertal milestones, breastfeeding?,
Menstrual History: oligomenorrhoea or 1/20 amenorrhoea, associated symptoms (eg. E deficiency, PRL symptoms, CHH features), medical & surgical history, family history, social history, medications/drugs

49
Q

How to examine for female infertility?

A

including BMI, sexual characteristics, hyperandrogenism signs, pelvic examination, other endocrine signs, syndromic features, anosmia

50
Q

What blood tests to do for female infertility?

A

LH, FSH, PRL

Oestradiol, Androgens

Foll phase 17-OHP, Mid- Luteal Prog

Sex Hormone Binding Globulin (SHBG)

Albumin, Iron studies

Also Pituitary/Thyroid profile

Karyotyping

51
Q

What tests to do for female infertility?

A

pregnancy hcg
urine test
chlamydia swab

52
Q

what imaging to do for. female infertility?

A

US (transvaginal)

Hysterosalpingogram

MRI Pituitary
(if low LH/FSH or high PRL)

Endocrinology (22 decks)

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