7. Infertility (lecture)

Question 1

what is the definition of infertility?

Answer 1

failure of conception in a couple having regular, unprotected coitus for one year

Question 2

what is primary and secondary infertility?

Answer 2

primary: no previous pregnancy
secondary: previous pregnancy, successful or not

Question 3

about how many couples will have difficulty conceiving in the UK?

Answer 3

1 in 7 couples

Question 4

what aspects of history do you ask for in an infertile female?

Answer 4

age
duration of infertility
menstrual cycle - length and predictability of cycle, age of menarche
tubal / pelvic surgery
PID
menorrhagia (abnormally heavy periods)
pelvic pain
sexual history - any infections?

Question 5

what aspects of history do you ask for in an infertile male?

Answer 5

general health
alcohol / smoking
previous surgery to the testes
drug history
previous infections
sexual dysfunction

Question 6

what do you examine in infertility?

Answer 6

BMI
signs of secondary sexual characteristics (e.g. chromosomal abnormalities)
galactorrhoea (milky secretion from the breasts)
pelvic examination - feel for structural abnormalities

Question 7

additionally, what do you check for in males?

Answer 7

testicular size and check for descent (from lumbar spine)

do NOT perform male examination without relevant history

Question 8

what are the most common aetiology of infertility?

Answer 8

male factors - 30%
Ovulatory disorders - 25%
tubal damage - 20%
uterine / peritoneal disease <10%
others (no identified male / female cause) - 25%

Question 9

what is the most common male factor causing infertility?

Answer 9

idiopathic oligospermia (deficiency of sperm cells in the semen)

Question 10

aside from idiopathic oligospermia, what are the other causes of infertility in males?

Answer 10

Varicocele
Abnormal sperm production (e.g. testicular disease)
Hypothalamic / pituitary dysfunction (not enough testosterone, so can’t produce sperm)
Ductal obstruction - post infective epididymitis, post vasectomy
Failure to deliver sperm to the vagina (hypospadias, impotence)

Question 11

what is hypospadias? (leading to failure to deliver sperm to vagina)

Answer 11

a congenital condition in males in which the opening of the urethra is on the underside of the penis (instead of at glans penis)

Question 12

what is impotence in men (leading to failure to deliver sperm to vagina)?

Answer 12

inability in a man to achieve an erection or orgasm

Question 13

what is varicocele in men (leading to infertility)?

Answer 13

when veins become enlarged inside scrotum

Question 14

what are the different classifications of ovulatory disorders?

Answer 14

1. Hypothalamic pituitary failure (GnRH to AP)
2. Hypothalamic-pituitary-ovarian dysfunction (GnRH, or AP affecting ovaries theca cells)
3. Ovarian failure (has stimulation but theca cells not producing oestrogen)

Question 15

what is polycystic ovary syndrome?

Answer 15

syndrome consisting of polycystic ovaries and systemic features resulting from elevated androgens

Question 16

what are the causes of polycystic ovary syndrome?

Answer 16

unknown pathophysiology, but appears to have genetic component

Question 17

what does polycystic ovary syndrome cause?

Answer 17

Increased androgen secretion (testosterone)
Raised LH/FSH ratio (disrupt ovulation, not enough FSH to cause follicles to mature in time for the LH surges)
Insulin resistance
Multiple small ovarian cyst
Anovulation

Question 18

what is anovulation in PCOS?

Answer 18

ovaries do not release an oocyte during a menstrual cycle, so no ovulation

Question 19

what are examples of anovulation in PCOS?

Answer 19

amenorrhoea (absence of menstrual periods)

oligomenorrhoea (infrequent menstrual periods)

Question 20

what are clinical features of ovulatory disorders e.g. PCOS?

Answer 20

Hirsutism 
Acne
Obesity
Male-pattern baldness
Oligomenorrhoea (infrequent menstrual periods)
Psychological symptoms

Question 21

what is Hirsutism in PCOS?

Answer 21

excessive body hair in men and women on parts of the body where hair is normally absent or minimal, such as on the chin or chest in particular

Question 22

what are psychological symptoms that can be present in PCOS?

Answer 22

mood swings
depression
anxiety

Question 23

what is the Rotterdam Diagnostic criteria for PCOS?

Answer 23

2/3 of the following:
Polycystic ovaries (12 or more follicles on ultrasound)
Oligo-ovulation / anovulation
Clinical and or biochemical signs of hyperandrogenism
Exclusion of other causes of androgen excess

Question 24

what is Oligo-ovulation? (PCOS)

Answer 24

infrequent, irregular ovulation

Question 25

what is anovulation? (PCOS)

Answer 25

the ovaries do not release an oocyte during a menstrual cycle, ovulation doesn't happen

Question 26

what is hyperandrogenism? (PCOS)

Answer 26

excess androgens (testosterone)

Question 27

what are causes of tubal damage causing infertility?

Answer 27

``` past pelvic infection e.g. Chlamydia previous pregnancies pelvic surgery endometriosis Mullerian developmental anomaly ```

Question 28

what is endometriosis? (cause of tubal damage causing infertility)

Answer 28

Presence of endometrial tissue in sites other than the uterine cavity (commonly pelvic cavity) affects 10-15% women (tissue that behaves like the lining of the womb (the endometrium) is found outside the womb)

Question 29

what does Mullerian duct form?

Answer 29

primordial anlage of the female reproductive tract: | fallopian tubes, uterus, the uterine cervix

Question 30

what are causes of uterine / peritoneal disease leading to infertility?

Answer 30

``` endometriosis Asherman's syndrome uterine fibroids cervical stenosis cervical hostility ```

Question 31

what causes cervical hostility?

Answer 31

infection or female sperm antibodies

Question 32

what is Asherman's syndrome? (cause of uterine / peritoneal disease leading to infertility)

Answer 32

formation of adhesions (scar tissue) inside the uterus and/or the cervix

Question 33

what are uterine fibroids? (cause of uterine / peritoneal disease leading to infertility)

Answer 33

benign smooth muscle tumours of the uterus (Most women have no symptoms while others may have painful or heavy periods. If large enough, they may push on the bladder causing a frequent need to urinate)

Question 34

what are clinical features of endometriosis?

Answer 34

Dysmenorrhoea (low anterior pelvic pain which occurs in association with periods) Dyspareunia (difficult or painful sexual intercourse) chronic pelvic pain infertility

Question 35

what are causes of other factors leading to infertility?

Answer 35

unexplained infertility poorly controlled diabetes coital problems (sex position) multifactorial in 5-10% of cases