Flashcards in Infertility Deck (51):
What is the function of LH in men? (1)
Stimulation of testosterone production from the Leydig cells in the testis.
Testosterone produces male secondary sexual characteristics.
Name 3. (3)
Pubic, axillary and facial hair
Enlargement of external genitalia
Deepening of the voice
Maintenance of libido
What is the distinction between primary, secondary and tertiary hypogonadism? (3)
1: disease of the testes
2: pituitary disease
3: hypothalamic disease
What is the most common congenital cause of male hypogonadism? (1)
Kleinfelter's (47 XXY)
Sterility and small firm testes
Name 4 causes of male hypogonadism. (4)
2'/3': Hypopituitarism, Severely underweight, Kallmann's syndrome, hyperprolactinaemia
congenital 1': Anorchia, Testicular maldescent (cryptorchidism), Chromosomal abnormality
acquired 1': Testicular torsion, Orchidectomy, Chemotherapy, Orchitis (mumps), CKD, Cirrhosis
What blood tests will help determine if male hypogonadism is primary or secondary/tertiary? (3)
Serum testosterone (confirm diagnosis)
Serum FSH/LH (low in 2' or 3'; high in 1' disease)
Further investigations can look for cause.
If primary likely: Chromosomal analysis
If secondary/tertiary: prolactin levels, pituitary MRI
What is Kallmann's syndrome? (2)
Deficiency of GnRH and associated anosmia and cleft palate.
How can male hypogonadism be managed? (2)
Cause is rarely reversible, but androgens can be replaced with testosterone and LH/FSH can be given when fertility is desired.
Define erectile dysfunction. (2)
Failure to initiate an erection or maintain an erection until ejaculation.
What is responsible for erections? (1)
Name 2 causes of ED affecting this mechanism. (2)
Increased vascularity of the penis controlled via sacral parasympathetic outflow.
Vascular disease, autonomic neuropathy (DM), nerve damage following surgery
Rupert attends the surgery regarding erectile dysfunction. He is able to achieve an erection and sometime has nocturnal emissions but is unable to when with his partner.
What does this history suggest the cause of his problem is? (1)
Psychosexual counselling may be helpful
Name 4 causes of ED? (4)
Pelvic surgery (nerve damage)
Traumatic nerve injury (lumbar sympathetic =ejeculation)
Autonomic neuropathy (diabetes)
What is sildenafil? (1)
Phosphodiesterase type 5 inhibitor
First line choice in erectile dysfunction (increases penile blood flow)
What is the physiology behind gynaecomastia? (1)
increased oestrogen:androgen ratio
Name 5 causes of gynaecomastia. (5)
Physiological: Pubertal, Old age
Deficient testosterone: hypogonadism
Oestrogen producing tumours: Testis or adrenal gland
HcG producing tumours: Testis or lung
Drugs: oestrogens, digoxin, cannabis; spironolactone
other: hyperthyroidism, breast carcinoma
What is the function of LH and FSH in women? (2)
LH: stimulates ovarian androgen production
FSH: Stimulates follicular developement and aromatase activity (androgens to oestrogens)
What blood test can be suggestive of menopause? (1)
FSH high first then LH is high due to lack of follicles.
Name 3 symptoms of the menopause. (3)
Hot flushes, vaginal dryness, breast atrophy, depression, loss of libido, weight gain.
Name 2 disadvantages to HRT. (2)
Risk of breast cancer
Risk of CHD
Endometrial cancer (if oestrogen only)
What are SERM's? (1)
Selective oestrogen receptor modulators. Positive oestrogen effects on bone but not on uterus or breasts.
Raloxifene is used to treat menopausal related osteoporosis.
What are primary and secondary amenorrhoea? (2)
Primary: failure to start periods by age 16
Secondary: absence of menstruation for 3 months in a woman who has had menarche.
How does hypogonadism in females present? (1)
Amenorrhoea or Oligomenorrhoea (<9 periods per year)
Name 5 causes of female hypogonadism. (5)
Hypothalamic: kallmann's, Anorexia, Post-COC
Pituitary: Hypopituitarism, Hyperprolactinaemia
Gonadal: PCOS, primary ovarian failure, Androgen secreting ovarian tumours, radiotherapy
Others: Thyroid dysfunction, Cushing's syndrome, Adrenal tumours, Imperforate hymen, Absent uterus
What is hirsutism? (2)
What does the presence of hirsutism suggest? (1)
Excess hair growth in women in a male pattern (androgen dependent): beard, abdominal wall, thigh, axilla and nipple area.
Increased androgen production by ovaries or adrenals.
What is hypertrichosis? (1)
Name 1 cause. (1)
General increase in body hair that is androgen independent.
Racial, genetic, anorexia, drugs (ciclosporin or phenytoin)
What is PCOS? (2)
Polycystic ovarian syndrome is characterised by multiple small cysts within the ovary (arrested follicular development) and by excess androgen secretion by the ovaries.
Name 3 associations with PCOS. (3)
Hyperinsulinaemia (and insulin resistance)
DM type 2
What are the features of PCOS? (3)
Clinical or biochemical evidence of hyperandrogenism
Polycystic ovaries on ultrasound
What is the management of PCOS? (3)
Hirsuitism: Oestrogens eg COC, cyproterone is anti-androgen, Spironolactone has antiandrogen activity, Finasteride inhibits dihydrotestosterone formation in the skin.
Menstrual disturbance: COC regulates cycles. Metformin helps hyperinsulinaemia, regulates cycle and aids weight loss.
Infertility: clomifene is anti-oestrogen used for induction of ovulation.
Define subfertility. (2)
No conception after one year of regular unprotected intercourse.
Affectes 15% of couples.
What are the four subheadings of problems that can cause subfertility? (4)
Adequate sperm (25%)
Sperm reach egg (30% tubal probs)
Embryo implants into uterus
How can ovulation be checked in a woman undergo in investigation for infertility? (3)
1. Serum progesterone levels in the mid-luteal phase of cycle (day 21/28)
2. Serial USS to monitor follicular growth (timely and uncommon)
3. LH-based urinary predictor tests
Name 3 causes of anovulation. (3)
PCOS*, Hypothalamic hypogonadism (anorexia)*, hyperprolactinaemia*, premature ovarian failure, gonadal dysgenesis, thyroid problems.
What is the treatment of infertility due to PCOS? (2)
First: clomifene (anti-oestrogen, inhibitors oestrogen receptors in the hypothalamus and pituitary). Promotes ovulation.
Second: metformin aims to restore ovulation, very low risk of multiple births, but lower overall birth rate so second line.
Fourth: ovarian diathermy
What is the main side effect of clomifene treatment for PCOS? (1)
Multiple births. more than one follicle can be stimulated.
Male factor subfertility accounts for 25% of couples.
What is a normal sperm analysis? (3)
Name 3 causes. (3)
Sperm count 15 million/ml
Idiopathic, varicocoele, anti-sperm antibodies (post-vasectomy reversal), alcohol, smoking, anabolic steroids, solvents.
Others: infections, CF (no vas deferens), hyperprolactinaemia
Define azoospermia. (1)
Define oligospermia. (1)
Define severe oligospermia. (1)
<5 million sperm
What is the management for oligospermia? (1)
Mild: intrauterine insemination (IUI)
Severe: IVF (with or without ICSI)
George has undergone semen analysis for subfertility, which has demonstrated azoospermia.
What are your next management steps? (2)
-Examine for vas deferens
-Karyotype, CF, hormone levels (LH and FSH for spermatogenesis)
-Surgical sperm retrieval for IVF and ICSI
What are the three classifications of problems relating to impaired fertilisation in infertility? (3)
Tubal*: PID, endometriosis, adhesions from surgery
How can fallopian tube latency be assessed? (2)
Laparoscopy and methylene blue test
Hysterosalpingogram: X-ray and radio-opaque injection
HyCoSy: ultrasound opaque injection and TVUS
Name three methods of assisted conception. (3)
What is IUI? (1)
Describe the process in basic. (1)
-washed sperm are injected directly into uterus
-requires patent tubes for travel of egg to uterus
-cheap but less successful than IVF
-can be used with normal cycles or induction of ovulation by gonadotrophins
What is the success rate of IVF? (2)
in woman 40y birth rate is <10%
IVF requires a normal ovarian reserve for collection of oocytes.
How can it be assessed? (2)
- FSH levels
- Anti-mullerian hormone levels
- Antral follicle count with TVUS
What is anti-mullerian hormone? (2)
Produced by follicles in ovaries, it is a reliable measure of ovarian reserve.
What are the stages of IVF? (4)
Multiple follicular development
Ovulatino and egg collection
Fertilisation and culture
Embryo transfer (no more than 2 if <40y)
What is ICSI? (2)
Intracytoplasmic sperm injection
One sperm is injected into the cytoplasm of oocyte.
useful for male factor infertility.
Who is oocyte donation used for? (1)
When women have ovarian failure, are older, or cannot use their own eggs through risk of disease.
Roy and Madge are a couple. They are both very unfortunate and both require oophorectomies.
How can their fertility be preserved? (3)