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BRS Year 2 > Infertility > Flashcards

Infertility Flashcards

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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 you have not had a live birth previously

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3
Q

What is secondary infertility?

A

When there has been a live birth in the past 12 months

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4
Q

What are the impacts of infertility on couples?

A 
Psychological:
no biological child
Impact on child wellbeing
Impact on larger family
Investigations
Treatment
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5
Q

What are the impacts of infertility on society?

A

Less births
Less tax income
Investigation
Treatment costs

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6
Q

What are pre testicular causes of infertility in males?

A

Congenital or acquired eg Klinefelter 47 XXY, Y chromosome deletion, HPG, Testosterone, Prolactin

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7
Q

What are testicular causes of infertility in males?

A 
Congenital
Cryptorchidism
Infections (STDs)
Immunological (Antisperm Abs)
Vascular (Varicocoele)
Trauma/ Surgery
Toxins (Chemo/DXT/Drugs/Smoking)
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8
Q

What are post testicular causes of infertility in males?

A 
Congenital (absence of vas deferens in CF)
Obstructive azoospermia
Erectile dysfunction (retrograde ejaculation, mechanical impairment, psychological)
Iatrogenic (vasectomy)
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9
Q

What is cryptorchidism? Where does it commonly happen in the body?

A

Undescended testes (90% in inguinal canal)

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10
Q

What are causes of infertility in females?

A 
Ovarian causes (40%)- anovulation, corpus luteum insufficiency
Tubal causes (30%) - tubulopathy due to infection, trauma, endometriosis
Uterine causes (10%) -unfavourable endometrium due to chronic endometriosis, fibroid, adhesions (synechiae), congenital malformation
Cervical causes (5%) - ineffective sperm penetration due to chronic cervicitis or immunological (antisperm Abs)
Unexplained (10%)
Pelvic causes (5%)- endometriosis, adhesions
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11
Q

What is endometriosis? How many women does it affect?

A

Presence of functioning endometrial tissue outside the uterus
5% of women
(responds to oestrogen)

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12
Q

What are symptoms of endometriosis?

A

Menstrual pain
Menstrual irregularities
Deep dyspareunia
Infertility

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13
Q

How is endomertriosis treated?

A

Hormonal (e.g. continuous OCP, prog)
Laparoscopic ablation
Hysterectomy
Bilateral Salpingo-oophorectomy

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14
Q

What are fibroids in infertile women? How many women does it affect?

A

Benign tumours of the myometrium
Affects 1-20% of pre-menopausal women (increases w age)
Responds to oestrogen

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15
Q

What are symptoms of fibroids?

A 
Usually asymptomatic
↑ Menstrual pain
Menstrual irregularities
Deep dyspareunia (painful ntercourse)
Infertility
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16
Q

How are fibroids treated?

A

Hormones (e.g. continuous OCP, prog, continuous GnRH agonists)
Hysterectomy

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17
Q

What are LH, FSH and testosterone levels in a male with hyperprolactinemia?

A

LH-low
FSH-low
Testosterone-low

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18
Q

What are LH, FSH and testosterone levels in a male with Klinefelters (primary testicular failure)?

A

LH- high
FSH-high
Testosterone-low

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19
Q

What male infertility problems arise due to hypothalamus problems?

A

Congenital hypogonadotropic hypogonadism (Kallmann syndrome- anosmic or normosmic)
Acquired hypogonadotropic hypogonadism (low BMI, excess exercise, stress)
Hyperprolactinaemia

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20
Q

What are Gnrh, LH, FSH, testosterone levels in infertile males when the problem is in the hypothalamus?

A

All low

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21
Q

What male infertility problems arise due to anterior pituitary problems?

A

Hypopituitarism: tumour, Infiltration, Apoplexy, Surgery, Radiation

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22
Q

What are LH, FSH, testosterone levels in infertile males when the problem is in the hypothalamus?

A

All low

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23
Q

What male infertility problems arise due to gonad problems?

A

Congenital primary hypogonadism (Klinefelters 47 XXY)

Acquired primary hypogonadism (cryptorchidism, trauma, chemo, radiation)

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24
Q

What are LH, FSH, testosterone levels in infertile males when the problem is in the testes?

A

LH/FSH high

Testosterone low

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25
What is Kallmann's syndrome?
Failure of migration of GnRH neurons with olfactory fibres (to the olfactory placode)
26
How will Kallmann's syndrome present?
``` Cryptorchidism Failure of puberty -Lack of testicle development -Micropenis -Primary amenorrhoea Infertility Anosmia ```
27
What hormone blocks kisspeptin neurones? How does it do this?
Prolactin binds to prolactin receptors on kisspeptin neurons in hypothalamus Inhibits kisspeptin release. Decreases downstream GnRH/LH/FSH/T/Oest
28
How does hyperprolactinemia present?
Oligo (>35d menses) or amenorrhoea (3-6m no menses)/ Low libido (and other hypogonadal symptoms)/ Infertility/ Osteoporosis
29
What are the causes of hyperprolactinaemia?
``` Prolactinoma Pituitary stalk compression Pregnancy and breastfeeding Medications (dopamine antagonists) PCOS Hypothyroidism ```
30
What happens to sex chromosomes in Klinefelter's?
Extra X chromosome (47 XXY)
31
How does Klinefelter's present?
``` Tall stature Low facial and chest hair Infertility (up to 3%) Mildly impaired IQ Breast development Small penis and testes Narrow shoulders Wide hips Low bone density Female like pubes ```
32
What should you include when taking history for an infertile man?
Duration, previous children, pubertal milestones, associated symptoms (eg. T deficiency, PRL symptoms, CHH features), medical & surgical history, family history, social history, medications/drugs
33
How should you examine an infertile man?
BMI, sexual characteristics, testicular volume, epididymal hardness, presence of vas deferens, other endocrine signs, syndromic features, anosmia
34
How is male infertility investigated
Semen Analysis Blood tests- LH, FSH, fasting testosterone, SHBG, albumin, iron, karyotyping Microbiology- urine test, chlamydia swab Imaging
35
What is the WHO criteria for normal semen analysis?
Volume: 1.5ml Sperm Conc. : 15 mil/ml Total motility: 40%)
36
What do we look for in a male infertility blood test?
LH, FSH, PRL Morning Fasting Testosterone Sex Hormone Binding Globulin (SHBG) Albumin, Iron studies Also Pituitary/Thyroid profile Karyotyping
37
What do we look for in a male infertility microbiology?
Urine test | Chlamydia swab
38
What lifestyle changes are advised for infertile males?
Optimise BMI Smoking cessation Alcohol reduction/cessation
39
What treatment is available for infertile males?
Dopamine agonist for hyperPRL Gonadotrophin treatment for fertility (will also increase testosterone) Testosterone (for symptoms if no fertility required – as this requires gonadotrophins) Surgery (eg. Micro Testicular Sperm Extraction (micro TESE))
40
Whats primary amenorrhea?
No period ever and >16 yrs old
41
Whats secondary amenorrhea?
Irregular periods, start but stop for 3-6 months
42
What would LH/FSH and oestradiol levels be in premature ovarian insufficiency?
LH-high FSH-high Oestradiol-low
43
What are symptoms of premature ovarian insufficiency (POI)?
Same as menopause
44
What are causes of POi
Autoimmune, genetic (fragile X or turner's syndrome), cancer therapy (radio/chemo in past)
45
What would LH/FSH and oestradiol levels be in anorexia nervosa induced amenorrhea?
LH-low FSH-low Oestradiol-low
46
What are Gnrh, LH, FSH, oestradiol levels in infertile females when the problem arises due to the hypothalamus?
All low
47
What are LH, FSH, oestradiol levels in infertile females when the problem arises due to the anterior pituitary?
All low
48
What are LH, FSH, oestradiol levels in infertile females when the problem arises due to the ovary?
LH/FSH high | Oestradiol low
49
What is the epidemiology of PCOS?
Most common cause of female infertility and most common female endocrine disorder Affects 5-15% of women of reproductive age Frequent family history
50
How is PCOS diagnosed?
2/3 out of: Oligo/anovulation- assessed by menstrual frequency: <21d or >35d cycles <8-9 cycles/y >90d for any cycle OR proven by lack of progesterone rise or US Hyperandrogenism- acne, hirsutism, alopecia, high androgens (testosterone) Polycystic ovaries: ≥20 follicles OR ≥10ml either ovary on TVUS (8 MHz)
51
How is PCOS amenorrhea treated?
Oral contraceptive pill | Metformin
52
How is PCOS increased insulin resistance treated?
Metformin
53
How is PCOS hirsutism treated?
Creams/wax/laser, anti androgens
54
How does turners present and in what gender?
``` Females: Short Low hairline Webbed neck Coarctation of aorta Underdeveloped reproductive tract Brown nevi Short 4th metacarpal Small finger nails Wide spaced nipples Poor breast development Amenorrhea ```
55
How should you take a history for an infertile female?
Duration, previous children, pubertal milestones, breastfeeding, Menstrual History: oligomenorrhoea or 1/20 amenorrhoea, associated symptoms, medical & surgical history, family history, social history, medications/drugs
56
How should you examine an infertile female?
BMI, sexual characteristics, hyperandrogenism signs, pelvic examination, other endocrine signs, syndromic features, anosmia
57
What are the main investigations for infertile females?
Blood test Pregnancy test Microbiology Imaging
58
Describe the difference between Klinefelters, Kallmanns, Turner's and fragile x syndrome
Klinefelter's- congenital primary testicular failure, extra x chromosome Kallmann's- congenital hypogonadotrophic hypogonadism (due to problems in the pituitary) Turner's- congenital female condition where they are partially missing an x chromosome Fragile X- congenital condition affecting x chromosome leading to developmental problems, intellectual disability etc
59
What is the most common cause of infertility in a couple?
Female factor (30%) Male and female factor (30%) Male factor (30%) Unknown (10%)
60
How many couples are affected by infertility?
Affects 1 in 7 couples (14%) | But half will conceive in next 12 months (at 24 months ~7 couples)
61
What percentage of infertile couples will seep help?
55% | Positive association with socioeconomic status
62
What are other causes of male infertility outside of the HPG axis?
Androgen receptor deficiency (rare) | Hyper/Hypothyroidism (reduces bioavailable testosterone)
63
What are GnRH, FSH, LH and T levels in Kallmann syndrome?
Low GnRH (not detectable) Low FSH/LH Low T
64
How is hyperprolactinemia treated?
Dopamine agonist (cabergoline) Surgery DXT
65
What imaging is done for male infertility?
Scrotal US/Doppler (for varicocoele/obstruction, testicular volume) MRI Pituitary (if low LH/FSH or high PRL)
66
What's the first thing to check for if a female presents with infertility symptoms?
Check they are not pregnant or breastfeeding
67
What is amenorrhea?
- No periods for at least 3-6 months. | - or up to 3 periods per year.
68
What is oligomenorrhea?
- Irregular or Infrequent periods >35 day cycles | - or 4-9 cycles per year.
69
How do we diagnose primary ovarian insufficiency?
High FSH >25 iU/L (x2 at least 4wks apart
70
How is hirsuitism assessed?
Ferriman- Gallwey score
71
How is alopecia assessed?
Ludwig score
72
What should you not use to assess Polycystic ovaries?
Do not use US until 8y post-menarche (due to high incidence of multi-follicular ovaries at this stage)
73
How is infertility in PCOS treated?
Clomiphene Letrozole IVF
74
What is a risk with PCOS and how is it treated?
Increase endometrial cancer risk (2-6) | Treat with progesterone cause
75
What blood tests are done for female infertility?
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
76
What type of pregnancy test do we do for female infertility?
Urine or serum HCG
77
What microbiology tests are done for female infertility?
Urine test Chlamydia swab
78
What imaging is done for female infertility?
US (transvaginal) Hysterosalpingogram MRI Pituitary (if low LH/FSH or high PRL)

BRS Year 2 (110 decks)

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