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Endo yr 2 > infertility > Flashcards

infertility Flashcards

1
Q

definition of 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 considered regular intercourse

A

every 2-3 days

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3
Q

prevelance of infertility and how many achieve it after an extra year of trying

A

14% of couples but half of these will achieve after extra year

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4
Q

how many couples with infertility seek help?

A

55%

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5
Q

which couples have been shown to be more likely to seek help concerning infertility?

A

higher socioeconomic status

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6
Q

what proportion of cases is due to 1) male factor 2) female factor 3) combination of male AND female factor 4) unknown

A

1,2,3; 33% each, unknown :10%

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7
Q

what is the cost of infertility to society?

A

Less births
- Less tax income
- Investigation costs
- Treatment costs

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8
Q

what are some of the issues that trouble couples with infertility psychologically?

A

No biological child
- Impact on couples wellbeing
- Impact on larger family
- Investigations
- Treatments (often fail) (eg ivf- 20-30 % of success)– money and psych
Discouraging

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9
Q

what are the three main categories of male infertility causes?

A

pre-testicular
testicular
post-testicular

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10
Q

what are the causes of pre testicular infertility

A

congenital and acquired endocrinopathies

1) Klinefelters 47XXY (extra x chormosome)
2) HPG,
T,
PRL issues (prolactin)

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11
Q

CAUSES OF TESTICULAR INFERTILITY

A

(Congenital)

Cryptorchidism

Infection STDs

Immunological Antisperm Abs

Vascular Varicocoele

Trauma/Surgery

Toxins
Chemo/DXT/Drugs/Smoking

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12
Q

causes of post testicular infertility

A

Congenital: Absence of vas deferens in CF

Obstructive: (obstruction of spermatic cord): Azoospermia

Erectile Dysfunction:
1)Retrograde Ejaculation 2)Mechanical Impairment 3) Psychological

Iatrogenic: Vasectomy

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13
Q

what is the normal path through which testes descent?

A

inguinal canal

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14
Q

what happens in cryptorchidism?

A

undescended testes,
90% in ingiunal canal

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15
Q

what are the categories of female infertility causes?

A

cervical, uterine, tubal, ovarian, pelvic (things that can happen in multiple areas of the female reprod system)

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16
Q

what are some pelvic (general) causes of infertility

A

endometriosis
adhesions

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17
Q

tubal causes of infertility and prevalence

A

30% infection
endometriosis
trauma

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18
Q

uterine causes and prevalence

A

10% Unfavourable endometrium due:
-Congenital malformations
-Infection/Inflammation/Scarring (adhesions)
-Fibroids

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19
Q

cervical causes and prevalence

A

(5%)
Ineffective sperm penetration due:
-Infection/Inflammation
-Immunological (antisperm Ab)

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20
Q

ovarian causes of infertility and prevalence

A

40%
anovulation (endo)
corpus luteum insufficiency

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21
Q

rank the causes of female infertility for prevalence

A

1) ovarian 40
2) tubal 30
3) unexplained and uterine 10 each
4) pelvic and cervical 5 each

(remember it by location, from ovary to cervic physiological path) (ovary-> tube-> uterus-> cervix)

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22
Q

above what point in the fem reprod system is there sterility?

A

cervix

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23
Q

what is endometriosis?

A

presence of functioning endometrial tissue outside the uterus

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24
Q

prevalence of endiometriosis

A

5% of women

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25
Q

what can be given to help with endometriosis?

A

oestrogen

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26
Q

symptoms of endometriosis

A

MENSTRUAL pain
menstrual irregularities
deep dyspareunia (pain before during or after sex)
infertility

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27
Q

what are fibroids?

A

benign tumours of the myometrium

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28
Q

prevalence of fibroids and what factor increases their prevalence?

A

1-20% of premenopausal women (increases with age)

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29
Q

what do fibroids responf to and why?

A

oestrogen because they are mad eup of uterine tissue

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30
Q

usual presentation of fibroids

A

1) usually asymptomatic
2) incr menstrual pain
3) menstrual irregularities
dyspareunia
infertility

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31
Q

where is kisspeptin released form and where does it act on?

A

kisspeptin neurons in hypothalamus and acts on gnrh neurons in hypothalamus

32
Q

which of the following are measurable in the blood? ( kisspeptin, gnrh and lh fsh)

A

only lh fsh

33
Q

in what rhythm is gnrh released

A

pulsatile

34
Q

what rhythm is lh and fsh released in

A

pulsatile

35
Q

what rhythm is oestrogena nd testosterone release in

A

diurnal

36
Q

is oestrogen produced from testosterone or test from oestrog by aromatisaiton

A

oestrog by testosterone (biology is sexist: way to remmebr)

37
Q

levels of lh fsh and test in any endocrine male infertility issue caused by any part of the HPG axis above the pituitary (hypothal or pit)?

A

all low
(hypogonadotrophic hypogonadism)

(in hypothalamus issues gnrh is additionally low but it cant be measured anyways)

38
Q

what do the terms: hypogonadotrophic hypogonadism mean and what is their significance?

A

hypogonadism : low test and oestrogen
hypogonadotrophic : low lh fsh
its not a diagnosis, just way to describe the situation

39
Q

levels of lh fsh and test in any gonad level caused endocrine male infertility

A

test low, lh fsh high

40
Q

hypothalamus level causes of endocrine male infertility?

A

congenital hypogonadotrophic hypogonadism (2 types-Anosmic (you cant smell) (Kallmann Syndrome) or Normosmic)

Acquired Hypogonadotrophic Hypogonadism
-Low BMI (anorexia nervosa: no , XS exercise, Stress

Hyperprolactinaemia

41
Q

when are these symptoms (of klinefelters syndrome) even more severe?

A

when 3 or more x chromosomes are present

42
Q

pituitary level causes of endocrine male infertility

A

Hypopituitarism
-Tumour, Infiltration (full of wbc), Apoplexy (blood flow interuption), Surgery, Radiation

43
Q

gonad level causes of endocrine male infertility

A

Congenital Primary Hypogonadism
-Klinefelters (47XXY)

acquired primary hypogonadism Cryptorchidism, Trauma, Chemo, Radiation

44
Q

what is kallmann syndrome?

A

the ANOSMIC type of CONGENITAL HYPOGONADOTROPHIC hypogonadism (at the HYPOTHALAMIC level)

45
Q

main symptoms of kallmann syndrome?

A

anosmia
reproductive features:
failure of puberty (Short, small penis)
infertility

46
Q

what is the pathology in kallmann syndrome

A

failure of migration of GnRH neurons with olfactory fibres from the olfactory placode (promitive nose) to the hypothalamus

47
Q

how does hyperprolactinaumia work?

A

prolactin binds on prolactin receptors on kisspeptin neurons inhibits kissp and the axis

48
Q

symptoms of hyperprolactinaemia in both men and women

A

(hypogonadal symptoms)
oligo or amenorrhoea
low libido
infertility/ osteoporosis

49
Q

what is klinefelter syndrome?

A

most common sex chromosome disorder - (sex chromosome trisomy) people have an extra x chromosome

50
Q

how common is klinefelter syndrome and how many cases get diagnosed?

A

1-2/ 1000 BIRTHS AND only 1/4 gets diagnosed

51
Q

what are the symptoms in klinefelters syndrome?

A

tall stature
mildly impaired IQ (15 POINTS DOWN ON AVERAGE)
low bone density

and female looking stuff:
1) female pubic pattern
2) small penis and testes
3) wide hips
4) narrow shoulders
5) little facial + chest hair (infrequent shaving)

52
Q

key history of male infertility

A

duration,
previous children,
pubertal milestones

53
Q

key examination of male infertility

A

BMI
sexual characteristics
testicular volume
anosmia

54
Q

key investigations for male infertility

A

1) semen analysis
2) blood tests
3) imaging

55
Q

normal semen volume, sperm concentration and total motility (proportion of sperm that can move)

A

1.5 ml
15 million
40%

56
Q

blood tests needed for male infertility

A

LH FSH PRL (prolactin)
Morning fasting testosterone
karyotyping

57
Q

imaging tests in male infertility

A

MRI pituitary (if low fsh/ lh or high prl)

SCROTAL US (ultrasound) / doppler: checks blood flow) (if variococoele/ obstruction, testicular volume)

58
Q

male infertility lifestyle treatments

A

Optimise BMI

Smoking cessation

Alcohol reduction/cessation

59
Q

male infertility specific treatments

A

Dopamine agonist for hyperPRL

Gonadotrophin treatment for fertility (will also increase testosterone)

Surgery
(eg. Micro Testicular Sperm Extraction (micro TESE))

60
Q

when do we give testosterone?

A

Testosterone
(for symptoms if no fertility required – as this requires gonadotrophins)

61
Q

what is the first thing you do to women with infertility symptoms?

A

ensure not pregnant or breastfeeding first

62
Q

symptoms of premature ovarian insufficiency

A

same as menopause

63
Q

conception rate in POI

A

20%

64
Q

causes of POI

A

Autoimmune
Genetic eg Turner’s Syndrome
Cancer therapy Radio- / Chemo-therapy in the past

65
Q

what is the cause of gonad level endocrine female infertility with incr lh fsh and normal or low e2?

A

polycystic ovarian syndrome (PCOS )

65
Q

HOW DO anorexia and stress induced amenorrhoea work?

A

Anorexia: no leptin: produced by fat cells
Stress: high cortisol: no periods
All these are sensed by kisspeptin neurons

Prevent periods bc its not safe to carry baby (if too thin or if too much stress)

66
Q

what are the causes of gonad level endocrine female infertility with incr lh fsh and low e2?

A

Acquired Primary Hypogonadism
-Premature Ovarian Insufficiency (POI)
-Surgery, Trauma, Chemo, Radiation

Congenital Primary Hypogonadism
-Turners (45X0)
-Premature Ovarian Insufficiency (POI)

67
Q

what is the most common speciifc cause of infertility in women?

A

PCOS - 5-15%, ALSO most common endocrine disorder in women

68
Q

PCOS diagnostic mehtod

A

1) exclude other causes of infertility
2) rotterdam pcos diagnostic criteria 2/3:
a) oligo or anovulation (assessed by menstrual freq)
b) Clinical +/- Biochemical Hyperandrogenism
c) polycystic ovaries

69
Q

PCOS symptoms

A

1) irregular menses/ amenorrhoea and infertility
2) incr insulin resistance and impaired glucose homeostasis (T2DM, gestational DM)
3) HIRSUTISM
4) incr risk of endometrial cancer

70
Q

what drugs are given for PCOS to help with a mix of the symptoms?

A

1) OCP for lighter periods and improves risk for endometr cancer
2)ovulation induction (IVF ) for infertility
3) metformin and diet-lifestyle for insulin issues and irregular menses and weight loss
4) anti androgens and hair removal for hirsutism
5) progesterone for enfometrial cancer rik

71
Q

what is turnners syndrome?

A

genetic disease cause of endocrine infertility (45 X)

72
Q

SYMPTOMS of turners syndrome appearance

A

head:
low hairline,
certain facies (grimatses),
webbed (short) neck

whole body:
short,
brown nevi (big moles)
-nipples big distance apart + poor breast dev

hands:
(shield chest) short fourth metacarpal
small fingernails
elbow deformity,

73
Q

health/ internal symptoms of turners syndrome

A

amenorrhoea
underdeveloped reproductive tract

74
Q

what thing do you do differently for womens key history for infertility?

A

menstrual history

75
Q

what do you do different for key for womens key examination for infertility?

A

hyperandrogenism signs

76
Q

key investigations differences for infertility for women

A

1) OU DO PREG TEST FIRST: common and cheap
2)oestradiol, androgens, mid luteal progesterone
3)hysterosalpinogram in imaging

Endo yr 2 (11 decks)

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