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Case 23 - Infertility > Infertility > Flashcards

Infertility Flashcards

(44 cards)

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1
Q

Definition of infertility

A

Inability to conceive after 1-2 years, regular and unprotected sex in absence of reproductive physiology

Investigate after 1 year unless women aged over 36, known cause of infertility, predisposing risk factors

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2
Q

Factors affecting fertility

A

Age (loss of no of oocytes, loss of oocyte quality)
Smoking
Alcohol
Obesity (BMI over 30 causes reduced fertility)
Low birth weight
Tight underwear
NSAIDs

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3
Q

HPG axis and requirements for fertility

A

1 - LH, FSH, Prolactin, TFTs
2 - Ovulation, sperm production
3 - Tubal potency, uterine anatomy

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4
Q

Anovulation causes (ovaries do not release oocyte during ovulation cycle)

A 
Polycystic ovary syndrome
Hypogonadotrophic hypogonadism
Premature ovarian insufficiency
Hyperprolactinaemia
Hypo/hyperthryoidism
Pregnancy
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5
Q

Polycystic ovary syndrome causes and criteria for diagnosing

A

Multifactorial - neural, metabolic, environmental, genetic

Rotterdam criteria:

  1. Oligo/amenorrhoea (menstruation)
  2. Hyperandrogenism/hyperandrogenaemia
  3. Polycystic ovaries on USS
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6
Q

Other things that can mimic PCOS

A

Congenital adrenal hyperplasia
Cushing’s
Androgen secreting tumour
Steroid abuse

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7
Q

PCOS signs/symptoms

A

Oligo/amenorrhoea
Hirsutism, acne, male patetrn balding
Obesity and metabolic syndrome

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8
Q

LT risks associated with PCOS

A

DMT2
Gestational diabetes
CVS and HTN
Endometrial hyperplasia and carcinoma

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9
Q

PCOS investigations

A

Elevated LH/FSH
Pelvic USS
Eleavted free T and FAI

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10
Q

Hypogonadotrophic hypogonadism/hypothalamic amenorrhoea

A

Low FSH and low estradiol
Hot flushes, vaginal dryness, mood changes (menopausal symptoms)

Causes - response to stress, pituitary surgery or irradiation, inflamm (sarcoidosis, TB),, congenital (kalimann’s syndrome), sheehans (postpartum pituitary necrosis)

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11
Q

Hypergonadotrophic hypogonadism/premature ovarian insufficiency

A

High FSH, high LH and low estradiol
Problem is ovary - menopausal symptoms

causes - idiopathc, automimmune, turner’s

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12
Q

Hyperprolactinaemia

A

High PRL
Micro PRL diagnostic, eleavted macro PRL not diagnostic

Oligomenorrhoea, headache, bitemporal hemianopia, galactorrhoea (milky nipple discharge)

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13
Q

Thyroid dysfunction

A

Anovulation
heavy menstrual bleeding
Miscarriage
Stillbirth

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14
Q

Tubal damage causes

A

Infection - PID, chlamydia, pelvic infection (appendicitis, septic miscarriage, TB), pelvic inflamm (Crohn’s), iatrogenic (adhesions post surgery), risk of ectopic pregnancy

Endometriosis - adhesions
Hydrosalphinx - fluid toxic to gametes/embryo

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15
Q

Uterine factors

A

Fibroids - subserosal, at tubal ostia - occlude passage, to uerine cavity - miscarriage, IUGR, PTL
Intrauterine adhesions - endometritis, trauma - excessive cutterage, ashermans’s
Congenital anomalies - same as general population, risk of miscarriage, associated renal onomalies, if found renal USS

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16
Q

causes of male infertility

A 
Test dysfunction
Obstructive
Varicocele
Endocrine
Autoimmune
Drugs
Environmental
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17
Q

testicular dysfunction

A

Most common
failure of spermatogenesis - trauma (tortion), crytorchidism, infection (recent UTI, mumps), neoplasm, chemo, Klinefelter’s

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18
Q

Obstructive causes of male infertility

Study These Flashcards
A

Azoospermia
Congenital - absence of vas
iatrogenic - vasectomy
Cystic fibrosis - bilateral vas absence

19
Q

varicocele causes of male infertility

Study These Flashcards
A

Abnormally tortuous veins in spermatic cord

May be present in fertile men, surgery if symptomatic but does not improve sperm count/qaulity

20
Q

endocrine causes of male infertility

Study These Flashcards
A

Hypogonadotrophic hypogonadism
kallmann - absent GnRH neurons, low LH and T, insomnia, failed pubertal, fertility - GnRH pump or LH/FSH infections
Puberty/libido - testosterone

Hyperprolactinaemia - impotence, normal semen analysis

21
Q

Autoimmune causes of male infertility

Study These Flashcards
A

Anti-sperm antibodies

22
Q

Drug causes of male infertility

Study These Flashcards
A

Recreational - tobacco, alcohol, marijuana
Anabolic and CCSs - may not be reversible
SSZ
Anti-fungals
Erectile dysfunction - BB, anti-depressants
Chemo

23
Q

Environmental causes of male infertility

Study These Flashcards
A

heat, radiation

24
Q

Unexplained causes of infertility

Study These Flashcards
A

Idiopathic
All investigations normal
maternal age main contributory factor

25
Investigations in infertility assessment for females
``` Reproductive hormones Ovulation Ovarian reserve/response to gonadotrophin stimulation Transvaginal USS Hysterosaphingography (HSG) Laparoscopy and dye test Rubella immunity Chlamydia trachomatis ```
26
Reproductive hormones for female infertility assessment
LH, FSH, PRL, TFTs, E2, T Day 1-5 (early follicular phase) Additional tests if abnormalities seen
27
Ovulation investigations for female infertility assessment
Menstrual regularity Mid-luteal progesterone - 7 days prior to next expected period progesterone >30nmol is ovulatory, in irregular cycle weekly urinary E2 and P4 4-6 weeks
28
Ovarian reserve/response to gonatrophin stimulation investigations for female infertility assessment
FSH >9 - poor response Anti-mullerian hormone - primordial follicles, high level >25 is god reserve, low level <5.4 is poor reserve Antral follicle count on USS - >16 is good response, <4 is poor response
29
Transvaginal USS for female infertility assessment
Ovary - antral follicle count, polycystic appearance of ovaries, ovarian cysts Uterus - endometrium, poylyps, fibroids, absent Tubes - hydrosalphinx
30
Hysterosalphingography (HSG) for female infertility assessment
Radio-opaque dye, X-ray,early follicular phase, abstinence, urinary hCG
31
Laparoscopy and dye test for female infertility assessment
``` Division of adhesions Diathermy of endometriosis Ovarian cystecomy Salphingectomy Tubal patency ```
32
Rubella immunity for female infertility assessment
``` Congenital infection Sensorineural deafness cardiac Opthalmic (cataracts, glaucoma) Microcephaly IUGR ```
33
Chlamydia trachomatis investigations for infertility assessment of female
PID, tubal damage | fetal conjuctivitis and pneumonia
34
Infertility assessment for men
Semen analysis - bio variation in quality, abstinence 3 days, avoid binge drinking, UTI/recent illness can affect sample Normal FSH and T - obstructive Low FSH and T - hypo hypogonadism (Kallmann's) Low FSH and high T - anabolics High FSH and normal T - failure of spermatogenesis High FSH and low T - complete testicular failure
35
general management of infertility
``` BMI normalisation Folic Acid 3 months pre-conception to 12 weeks Smoking cessation Cut alcohol intake Regular unprotected intercourse ```
36
Management of PCOS
BMI <35 Clomiphene anti-oestrogen, raises FSH, induces folliculogenesis Gonadotropin therapy - daily FSH till pre-ovulatory follicle, USS monitoring laparoscopic ovarian drilling IVF
37
Management of hypothalmic amenorrhoea
Increase weight Decrease exercise Daily FSH and hCG for ovulation GnRH pulsatile administration
38
Hypogonadotrophic hypogonadism
``` No follicles Ovulation induction not possible WIll not respond to gonadotrophins Egg donation Adoption ```
39
Hyperprolactinaemia management
Dopamine agonists - bromocriptine | Transphenoidal pituitary surgery
40
Tubal factor management
Surgery for some Specialist centres Risk of ectopic pregnancy IVF
41
Uterine factors management
case-by-case basis Hysteroscopic resection for submucosal fibroid and uterine polyp Intramural fibroids - myomectomy Adhesions - copper coil, hysteroscopic division
42
Male factor management
``` Intracytoplasmic sperm injection if oligospermia/poor morphology/motility Obstructive - surgical retrieval and insemination Hypogonadtophic hypogonadism - gonadotrophic therapy Anabolics - expectant if recovered, IVF/ICSI if partial recovery, donor sperm if no recovery Failing spermatogenesis (Klinefelters) - sperm freezing Testicular failure (chemo) - sperm freezing if time, donor sperm ```
43
Management of unexplained infertility
Regular unprotected intercourse No ovulation induction as ovulates No gonadotrophins as normal HPG axis IVF after 2 yrs unprotected regular intercourse
44
IVF
Aim to induce as many follicles as possible Downregulation with GnRH analogues Daily FSH Frequent USS monitoring Egg collection 36-38h from trigger Semen collection Oocytes and sperm incubated overnight or intracytoplasmic sperm injection Embryo transfer day 3 or day 5 blastocyst One embryo transfer Risks - failed cycle, bowel/vessel injury, infection, miscarriage, ectopic, multiple pregnancy

Case 23 - Infertility (3 decks)

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