1b Infertility

Question 1

What is Infertility?

Answer 1

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

Question 2

What is primary infertility?

Answer 2

not had a live birth previously

Question 3

What is secondary infertility?

Answer 3

Had a live birth over 12 months ago

Question 4

What is the most common cause on infertility?

Answer 4

Combined Male and Female Factors

Question 5

Cost of infertility to the couple:

Answer 5

• No biological child
• Impact on couples wellbeing
• Impact on larger family
• Treatments and Investigations (which often fail = more distress)

Question 6

What is the cost of infertility to society?

Answer 6

• Less births
• Less tax income
• Investigation costs
• Treatment costs

Question 7

What are the pre-testicular causes of infertility? - MALE

Answer 7

Endocrinopathies eg Klinefelter 47XXY
Issues with HPG Axis, T, PRL

Question 8

What is cryptochordism?

Answer 8

Undescended testis - testis start embryologically in the inguinal canal, therefore undescended means they are left there

Question 9

What toxins can cause infertility?

Answer 9

Chemo, Toxins, Drugs, Smoking

Question 10

What are the testicular causes of Infertility

Answer 10

Cryptochordism
Immunological
Vascular
Trauma / Surgery
Toxins
Infection

Question 11

What are the post testicular causes of infertility?

Answer 11

Congenital - absense of vas deferens
Obstructive Azoospermia
Erectile Dysfunction
Iatrogenic

Question 12

What are the uterine causes of infertility?

Answer 12

Congenital Malformation
Infection
Scarring/Inflammation/Adhesions/Fibroids

Question 13

What are the tubular causes of infertility? - FEMALE

Answer 13

Infection, Trauma, Endometriosis

Question 14

What are the ovarian causes of infertility?

Answer 14

Anovulation - no ovulation
Corpus Luteum Insufficiency

Question 15

What is endometriosis?

Answer 15

Presence of functioning endometrial tissue outside the uterus

Question 16

Why does endometriosis cause increased period pains

Answer 16

Endometriosis responds to oestrogen
Mid cycle oestrogen increases therefore exacerbates menstrual pain

Question 17

What are the symptoms of endometriosis?

Answer 17

Increased menstrual Pain
Menstrual irregularities
Deep dyspareunia
Infertility

Question 18

What are fibroids?

Answer 18

BENIGN TUMOURS OF THE MYOMETRIUM

Question 19

What are the symptoms associated with fibroids?

Answer 19

Usually Asymptomatic
Increased menstrual Pain
Menstrual irregularities
Deep dyspareunia
Infertility

Question 20

How is Oestrogen made in Males?

Answer 20

Aromatised from testosterone

Question 21

Describe the HPG Axis?

Answer 21

1. kiss peptin binds to kiss peptin receptors
2. Stimulates GnRH release
3. Binds to gonadotrophs - FSH and LH secretion, which leads to T and O secretion

Question 22

Describe the hormone profile in hyperprolactinaemia?

Answer 22

↓GnRH (Not measurable in the systemic circulation)
↓LH
↓FSH
↓Testosterone

Question 23

Hormone profile in Kallmann syndrome?

Answer 23

All decreased
Hypogonadotrophic and hypogonadism

Question 24

How does hyperprolactinaemia cause decreased hormones?

Answer 24

Prolactin binds to kisspeptin neurons in hypothalamus

Inhibits kisspeptin release

Decreases downstream GnRH/LH/FSH/T/Oest

Causes oligo or amenorrhoea or low labido

Question 25

Treatment for hyperprolactinaemia

Answer 25

Dopamine agonist

Question 26

What can cause hypopituitarism?

Answer 26

Apoplexy, Tumour, Infiltration, Surgery, Radiation

Question 27

What is the hormone profile in hypopituitarism?

Answer 27

↓LH ↓FSH ↓Testosterone

Question 28

What is congenital Primary Hypogonadism in males?

Answer 28

Klinefelters (47XXY)

Question 29

What is the hormone profile in Klinefelters?

Answer 29

↑LH ↑FSH ↓Testosterone

Question 30

What cause cause acquired primary hypogonadism?

Answer 30

Cryptochordism, Trauma, Chemo, Radiation

Question 31

What is the cause of Kallmanns Syndrome?

Answer 31

Failure of migration of GnRH neurones with the olfactory fibres - can lead to anosmia Causes failure of puberty Infertility

Question 32

What are the symptoms of Klinefelter?

Answer 32

Tall Mildly Impaired IQ Reduced Chest Hair Wide Hips Low Bone Density Small Penis / Testes Breast Development Female Like Pubic Hair Patterns

Question 33

What are the blood tests which should be conducted for Male Infertility?

Answer 33

LH, FSH, PRL Morning Fasting Testosterone - Highest in the morning, and fasting as glucose can impact T Karyotyping Semen Analysis

Question 34

What imaging should be conducted for. male infertility investigation?

Answer 34

Scrotal US / Doppler - if Testicular Volume is irregular Pituitary MRI - if LH, FSH eetc is low

Question 35

What are the key examinations which should be performed for investigating male infertility?

Answer 35

BMI, sexual characteristics, testicular volume, anosmia

Question 36

What are the lifestyle treatments for male infertility?

Answer 36

Optimise BMI Smoking Cessation Alcohol Reduction

Question 37

How is male infertility treated?

Answer 37

Gondaotrophin treatment Dopamine agonist for hyperPRL Testorone for symptoms Surgery eg micro testicukar sperm extraction)

Question 38

Why is giving males only testosterone not helpful in increasing fertility?

Answer 38

Will treat low libido, and other associated symptoms, however testosterone inhibits sperm production so therefore will not help fertility

Question 39

Describe the hormone profile seen in Premature Ovarian Insufficiency?

Answer 39

↑LH ↑FSH ↓Oestradiol

Question 40

What test results are needed to diagnose Premature Ovarian Insufficiency?

Answer 40

High FSH (>25iU/L) - x2 at least 4 weeks apart

Question 41

What are the causes of premature ovarian Insufficiency?

Answer 41

Autoimmune Genetics eg Turners Cancer Therapy

Question 42

What is the hormone profile in hypothalamic amenorrhoea?

Answer 42

↓GnRH - Not Measureable ↓LH ↓FSH ↓E2

Question 43

What is the hormone profile seen in PCOS?

Answer 43

↓E2 ↑LH:FSH Ratio

Question 44

Describe the causes of congenital Primary Hypogonadism in females?

Answer 44

turners Syndrome Premature Ovarian Insufficiency

Question 45

What are the three Rotterdam PCOS Diagnostic?

Answer 45

1. Oligo (8-9 cycles a year)/ Anovulation 2. Clinical +/- Biochemical Hyperandrogenism 3. Polycystic Ovaries (Polycystic Ovaries morphology are not the same as the syndrome)

Question 46

What are the treatment options for Irregular Menses?

Answer 46

oral Contraceptive Pill and IVF

Question 47

What are the treatment options for Insulin Resistance?

Answer 47

Metformin, Diet and Lifestyle

Question 48

What are the treatment options for Hirsutism?

Answer 48

Creams, Waxing and Laser Anti-Androgens like spironolone = Mineralcorticoid receptor antagonist

Question 49

What are the implications of PCOS?

Answer 49

Irregular Menses Infertility Increased Insulin Resistance Hirsutism Increased Endometrial cancer Risk

Question 50

Describe the hormone profile in turners Syndrome?

Answer 50

↑LH ↑FSH ↓Testosterone = Hypergonadotrophic hypogonadism

Question 51

What are the signs of Turner's Syndrome?

Answer 51

Short Stature Low Hairline Shield Chest Wide Spaced Nipples Small Finger Nails Brown Nevi Webbed Neck Poor Breast Development Amenorrhoea Coractation of the Aorta

Question 52

What blood tests should be done when investigating female infertility?

Answer 52

LH FSH PRL Oestradiol, Androgens Mid-Luteal Progesterone Karyotyping

Question 53

What is a cause of uterine infertility which is oestrogen responsive?

Answer 53

fibroids

Question 54

What is klinefelters also known as?

Answer 54

Primary testicular failure

Question 55

In Kallmann Syndrome, where are the neurones supposed to migrate to and from?

Answer 55

From the hypothalamus to the olfactory placode

Question 56

What is premature ovarian insufficiency also known as?

Answer 56

early menopause

Question 57

what hormone pattern would you see in anorexia nervosa-induced amenorrhoea?

Answer 57

LH Down FSH Down and Oestradiol Down

Question 58

What imaging is done in female infertility?

Answer 58

US transvaginal Hysterosalpingogram MRI Pituitary