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Year 2 Endo > 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 have had a live birth >12 months previously

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4
Q

Describe the epidemiology of infertility?

A

Affects 1 in 7 couples
But ~ half of these will then conceive in the next 12 months

55% will seek help positive association with socioeconomic status

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5
Q

What is the epidemiology of infertility? i.e which person %

A

Female 30%
Male 30%
Combined 30%
Unknown 10%

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6
Q

Why might infertility cause psychological distress to a couple?

A
  • No biological child
  • Impact on couples wellbeing
  • Impact on larger family
  • Investigations
  • Treatments (often fail)
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7
Q

What is the cost of infertility to the society?

A
  • Less births
  • Less tax income
  • Investigation costs
  • Treatment costs
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8
Q

What three types of causes of infertility in males?

A

Pre-testicular
Testicular
Post-testistcular

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9
Q

What is pre-testicular infertility?

A

Congenital & Acquired Endocrinopathies
Klinefelters 47XXY
Y chromosome deletion
HPG, T, PRL

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10
Q

What is testicular infertility?

A

(Congenital)

Cryptorchidism

Infection
STDs

Immunological
Antisperm Abs

Vascular
Varicocoele

Trauma/Surgery

Toxins Chemo/DXT/Drugs/Smoking

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11
Q

What is post-testicular infertility?

A

Congenital Absence of vas deferens in CF

Obstructive Azoospermia

Erectile Dysfunction Retrograde Ejaculation Mechanical Impairment Psychological

Iatrogenic Vasectomy

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12
Q

What is CRYPTORCHIDISM?

A

Undescended testis

90% in inguinal canal

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13
Q

What are the categories of causes in females?

A 
Ovarian causes
Tubal causes
Uterine causes 
Cervical causes
Pelvic causes
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14
Q

What are ovarian causes?

A

-Anovulation (Endo)
-Corpus luteum insufficiency
40%

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15
Q

What are tubal causes?

A

Tubopathy due:

  • Infection
  • Endometriosis
  • Trauma

30%

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16
Q

What are uterine causes?

A

Unfavourable endometrium due:

  • Chronic endometritis (TB)
  • Fibroid
  • Adhesions (Synechiae)
  • Congenital malformation
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17
Q

What are cervical causes?

A

Ineffective sperm penetration due:

  • Chronic cervicitis
  • Immunological (antisperm Ab)

5%

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18
Q

What are pelvic causes?

A
  • Endometriosis
  • Adhesions

5%

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19
Q

What is endometriosis?

A

Presence of functioning endometrial tissue outside the uterus

  • 5% of women
  • Responds to oestrogen
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20
Q

What are symptoms of endometriosis?

A

Increased Menstrual pain
Menstrual irregularities
Deep dyspareunia
Infertility

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21
Q

What are the treatments for endometriosis?

A

Hormonal (eg continuous OCP, prog)
Laparascopic ablation
Hysterectomy
Bilateral Salpingo-oophorectomy

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22
Q

What are fibroids?

A
  • 1-20% of pre-menopausal women (increases w age)

- Respond to oestrogen

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23
Q

What are symptoms of fibroids?

A 
Usually asymptomatic
Increased Menstrual pain
Menstrual irregularities
Deep dyspareunia
Infertility
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24
Q

What are treatments for fibroids?

A

Hormonal (eg continuous OCP, prog, continuous GnRH agonists)

Hysterectomy

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25
What pattern of LH/FSH and testosterone would you see in hyper prolactinaemia?
All low
26
What pattern of LH/FSH and testosterone would you see in Klinefelters?
High FSH/LH Low T
27
What can cause endocrine male infertility?
Androgen receptor deficiency (rare) Hyper/hypothyrodism
28
What congential causes cause low GnRH?
Congenital Hypogonadotrophic Hypogonadism -Anosmic (Kallmann Syndrome) or Normosmic
29
What acquired causes cause low GnRH?
Acquired Hypogonadotrophic Hypogonadism - Low BMI, XS exercise, Stress - Hyperprolactinaemia
30
What are the pituitary causes of Male infertility?
Hypopituitarism -Tumour, Infiltration, Apoplexy, Surgery, Radiation
31
What are the gonadal (affects testes, congenital & acquired) causes of male infertility?
Congenital Primary Hypogonadism -Klinefelters (47XXY) Acquired Primary Hypogonadism -Cryptorchidism, Trauma, Chemo, Radiation
32
What is Kallmann syndrome?
Failure of migration of GnRH neurones with olfactory fibres into the hypothalamus Low GnRH Low LH/FSH Low T
33
What are the symptoms of Kallmann syndrome?
``` Cryptorchidism Failure of puberty -Lack of testicle dvlpt -Micropenis -Primary amenorrhoea Infertility ``` Anosmia
34
What does prolactin do to cause infertility?
Prolactin binds to receptors on kisspeptin neurons Inhbits kisspeptin release Decrease GnRH/LH/FSH/T/Oest Oligomenhorrea/Amenorrhea/Low libido
35
How do you treat hyperprolactinaemia?
``` Dopamine agonist (Cabergoline) Surgery/DXT ```
36
What causes hyperprolactinaemia?
Prolactinoma (micro/macro) Pituitary stalk compression Pregnancy & Breastfeeding Medications (Dop antagonists eg anti-emetics and antipsychotics) (Oestrogens eg OCP) PCOS Hypothyroidism
37
What is Kleinfelter's syndrome? And its' effects on hormone levels
XXY Increase LH and FSH Low T
38
What are the features/symptoms of Kleinfelters?
``` Tall Low facial hair Breast development Female-type pubic hair Small penis and testes Infertility Mildy impaired IQ Narrow shoulders Reduced chest hair Wide hips Low bone density ```
39
What do you ask when talking an infertility history?
``` duration previous children pubertal milestones associated symptoms (eg. T deficiency, PRL symptoms, CHH features) medical & surgical history family history social history medications/drugs ```
40
What do you examine when looking at infertility? Which features?
including BMI, sexual characteristics, testicular volume, epididymal hardness, presence of vas deferens, other endocrine signs, syndromic features, anosmia
41
What investigations (tests) can be conducted to determine cause of infertility?
Semen analysis Blood tests (LH/FSH/PRL) Micrbiology Imaging
42
What blood test are conducted? (male)
LH, FSH, PRL Morning Fasting Testosterone Sex Hormone Binding Globulin (SHBG) Albumin, Iron studies Also Pituitary/Thyroid profile Karyotyping
43
What is azoospermia?
No sperm
44
What is oligospermia?
Reduced sperm
45
What microbiology is conducted? (male)
Urine test Chlamydia swab
46
What imaging can be conducted to determine cause of male infertility?
Scrotal US/Doppler (for varicocoele/obstruction, testicular volume) MRI Pituitary (if low LH/FSH or high PRL)
47
What are the general lifestyle treatments for male infertility?
Optimise BMI Smoking cessation Alcohol reduction/cessation
48
What are the specific treatments for male infertility?
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))
49
What is POI?
Premature Ovarian Insufficiency
50
What are the symptoms of POI?
Same as menopause
51
What causes POI?
Autoimmune Genetic eg Fragile X Syndrome / Turner’s Syndrome Cancer therapy Radio- / Chemo-therapy in the past
52
What causes low GnRH in women? (congenital)
Congenital Hypogonadotrophic Hypogonadism | -Anosmic (Kallmann Syndrome) or Normosmic
53
What causes low GnRH in women? (acquired)
Acquired Hypogonadotrophic Hypogonadism -Low BMI, XS exercise, Stress Hyperprolactinaemia
54
What are the pituitary causes of female infertility?
Tumour, Infilatration, Apoplexy, Surgery, Radiation
55
What causes female infertility at the gonad level?(aquired)
PCOS Premature Ovarian Insufficiency (POI) -Surgery, Trauma, Chemo, Radiation
56
What causes female infertility at the gonad level?(congenital)
- Turners (45X0) | - Premature Ovarian Insufficiency (POI)
57
What is PCOS? (epidemiology)
Affects 5-15% of women of reproductive age Frequent family history Most common endocrine disorder in women Most common cause of infertility in women
58
What is the Rotterdam PCOS diagnostic criteria?
2 out of 3 Oligo or Anovulation Clinical +/- biochemical hyperandrogegism Polycystic ovaries
59
How do you assess menstrual frequency?
<21d or >35d cycles <8-9 cycles/y >90d for any cycle
60
How do you assess hyperandrogenism?
CLINICAL Acne, hirsutism (Ferriman-Gallwey score), alopecia (Ludwig score) ``` BIOCHEMICAL Raised androgens (eg Testosterone) ```
61
How do you assess cysts?
≥20 follicles OR ≥10ml either ovary on TVUS (8 MHz) Do not use US until 8y post-menarche (due to high incidence of multi-follicular ovaries at this stage)
62
What is the treatments for PCOS?
``` Metformin Oral contraceptive pill Anti-androgens Creams, waxing, laser Progesterone courses ```
63
What are the symptoms of PCOS?
``` Irregular menses Infertility Increased insulin resistance Impaired glucose homeostasis Hirtuism Increased endometrial cancer risk ```
64
What are the features of Turners?
``` Short stature Low hairline shield chest Wide-space nipples Short 4th metacarpal Small fingernails Brown nevi Characteristic faces Webbed neck Coarctation of aorta Poor breast development Elbow deformity Underdeveloped reproductive tract Amenorhea ```
65
What do you ask in a fertility history? (female)
including duration, previous children, pubertal milestones, breastfeeding?, Menstrual History: oligomenorrhoea or 1/20 amenorrhoea, associated symptoms (eg. E deficiency, PRL symptoms, CHH features), medical & surgical history, family history, social history, medications/drugs
66
What is involved in a fertility examination? (female)
including BMI, sexual characteristics, hyperandrogenism signs, pelvic examination, other endocrine signs, syndromic features, anosmia
67
What blood test are conducted? (female)
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
68
What biochemical test are conducted (female infertility)?
Pregnancy Test (urine or serum HCG Urine test Chlamidya swab
69
What imaging is used to diagnose infertility in women?
US (transvaginal) Hysterosalpingogram MRI Pituitary (if low LH/FSH or high PRL

Year 2 Endo (15 decks)

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