Infertility

Question 1

What is infertility?

Answer 1

A disease of the reproductive system defined by the failure to achieve a clinical pregnancy after ≥12 months of regular unprotected sexual intercourse

Question 2

What is primary infertility?

Answer 2

When you have not had a live birth previously

Question 3

What is secondary infertility?

Answer 3

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

Question 4

What are the impacts of infertility on couples?

Answer 4

Psycological:

no child, family, treatement impact

Question 5

What are the impacts of infertility on society?

Answer 5

Less births
Less tax income
Treatment costs

Question 6

What are pre testicular causes of infertility in males?

Answer 6

Congenital or accquired eg Klinefeters, Y chromsome loss

Question 7

What are testicular causes of infertility in males?

Answer 7

Congenital, STD/infections, immunological, vascular, trauma, toxins

Question 8

What are post testicular causes of infertility in males?

Answer 8

Congenital, obstructive azoospermia, erectile dysfunction, latrogenic

Question 9

What is cryptochidism?

Answer 9

Undescended testes (should be through inguinal canal)

Question 10

What are causes of infertility in females?

Answer 10

Ovarian causes- anovulation, corpus luteum insufficiency
Tubal causes- tubopathy due to infection, trauma, endometriosis
Uterine causes- endometriosis, fibroid, adhesions
Cervical causes- ineffective sperm penetration sue to chronic cervicitis or immunological

Question 11

What is endometriosis?

Answer 11

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

Question 12

What are symptoms of endometriosis?

Answer 12

Menstrual pain
Pain on intercourse
Menstrual irregularities
Infertility

Question 13

How is endomertriosis treated?

Answer 13

Hormonal
Laparascopic ablation
Hysterectomy
Bilateral Salpingo-oophorectomy

Question 14

What are fibroids in infertile women?

Answer 14

Benign tumours of the myometrium

Question 15

What are symptoms of fibroids?

Answer 15

Usually asymptomatic
↑ Menstrual pain
Menstrual irregularities
Deep dyspareunia
Infertility

Question 16

How are fibroids treated?

Answer 16

Hormones

Hysterectomy

Question 17

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

Answer 17

LH-low
FSH-low
Testosterone-low

Question 18

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

Answer 18

LH- high
FSH-high
Testosterone-low

Question 19

What male infertility problems arise due to hypothalamus problems?

Answer 19

Congenital hypoganadotrophic hypogonadism (Kallmann syndrome)
Acquired hypoganadotrophic hypogonadism (low BMI, exercise, stress)
Hyperprolactinaemia

Question 20

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

Answer 20

All low

Question 21

What male infertility problems arise due to anterior pituitary problems?

Answer 21

Hypopituitarism, tumour, Infiltration, Apoplexy, Surgery, Radiation

Question 22

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

Answer 22

All low

Question 23

What male infertility problems arise due to gonad problems?

Answer 23

Klinefelters

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

Question 24

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

Answer 24

LH/FSH high

Testosterone low

Question 25

What is Kallmann's syndrome?

Answer 25

Failure of migration of GnRH neurons with olfactory fibres

Question 26

How will Kallmann's syndrome present?

Answer 26

``` Cryptorchidism Failure of puberty -Lack of testicle development -Micropenis -Primary amenorrhoea Infertility Anosmia ```

Question 27

What hormone blocks kisspeptin neurones?

Answer 27

Prolactin

Question 28

How does hypogonadism present?

Answer 28

Oligo or amenorrhoea /Low libido/ Infertility/Osteoporosis

Question 29

What are the causes of hyperprolactinaemia?

Answer 29

``` Prolactinoma Pituitary stalk compression Pregnancy and breastfeeding Medications (dopamine antagonists) PCOS Hypothyroidism ```

Question 30

What happens to sex chromosomes in Klinefelter's?

Answer 30

Extra X chromosome (XXY)

Question 31

How does Klinefelter's present?

Answer 31

``` Tall stature Low facial and chest hair Breast development Small penis and testes Wide hips Low bone density Female like pubes Narrow shoulders ```

Question 32

What should you include when taking history for an infertile man?

Answer 32

Duration, previous children, pubertal milestones, associated symptoms (eg. T deficiency, PRL symptoms, CHH features), medical & surgical history, family history, social history, medications/drugs

Question 33

How should you examine an infertile man?

Answer 33

BMI, sexual characteristics, testicular volume, epididymal hardness, presence of vas deferens, other endocrine signs, syndromic features, anosmia

Question 34

What are the main investigations for infertile males?

Answer 34

Semen analysis Blood tests- LH, FSH, fasting testosterone, SHBG, albumin, iron, karyotyping Microbiology- urine test, chlamydia swab Imaging

Question 35

What should male sperm vol be?

Answer 35

1.5 ml

Question 36

What should sperm count be?

Answer 36

15 mill/ml

Question 37

What should sperm motility be?

Answer 37

40%

Question 38

What lifestyle changes are advised for infertile males?

Answer 38

Optimise BMI Smoking cessation Alcohol reduction/cessation

Question 39

What treatment is available for infertile males?

Answer 39

Dopamine agonist for hyperprolactinemia Gonadotrophin treatment for fertility (will also increase testosterone) Testosterone (for symptoms if no fertility required – as this requires gonadotrophins) Surgery

Question 40

Whats primary amenorrhea?

Answer 40

No period ever and >16 yrs old

Question 41

Whats secondary amenorrhea?

Answer 41

Irregular periods, start but stop for 3-6 months

Question 42

What would LH/FSH and oestradiol levels be in premature ovarian insufficiency?

Answer 42

LH-high FSH-high Oestradiol-low

Question 43

What are symptoms of premature ovarian insufficiency (POI)?

Answer 43

Same as menopause

Question 44

What are causes of POi

Answer 44

Autoimmune, genetic (fragile X or turners), cancer therapy

Question 45

What would LH/FSH and oestradiol levels be in anorexia nervosa induced amenorrhea?

Answer 45

LH-low FSH-low Oestradiol-low

Question 46

What are Gnrh, LH, FSH, oestradiol levels in infertile females when the problem arises due to the hypothalamus?

Answer 46

All low

Question 47

What are LH, FSH, oestradiol levels in infertile females when the problem arises due to the anterior pituitary?

Answer 47

All low

Question 48

What are LH, FSH, oestradiol levels in infertile females when the problem arises due to the ovary?

Answer 48

LH/FSH high | Oestradiol low

Question 49

What is PCOS?

Answer 49

Most common cause of female infertility

Question 50

How is PCOS diagnosed?

Answer 50

2/3 out of: Oligo/anovulation- assessed by menstrual frequency Hyperandrogenism- acne, hirtuism, alopecia, high testosterone Polycystic ovaries

Question 51

How is PCOS amenorrhea treated?

Answer 51

Oral contraceptive pill | Metformin

Question 52

How is PCOS increased insulin resistance treated?

Answer 52

Metformin

Question 53

How is PCOS hirtuism treated/

Answer 53

Creams/wax/laser, anti androgens

Question 54

How does turners present and in what gender?

Answer 54

``` Females: Short Low hairline Wide spaced nipples Poor breast development Amenorrhea ```

Question 55

How should you take a history for an infertile female?

Answer 55

Duration, previous children, pubertal milestones, breastfeeding, Menstrual History: oligomenorrhoea or 1/20 amenorrhoea, associated symptoms, medical & surgical history, family history, social history, medications/drugs

Question 56

How should you examine an infertile female?

Answer 56

BMI, sexual characteristics, hyperandrogenism signs, pelvic examination, other endocrine signs, syndromic features, anosmia

Question 57

What are the main investigations for infertile females?

Answer 57

Blood test Pregnancy test Microbiology Imaging

Question 58

Describe the difference between Klinefelters, Kallmanns, Turner's and fragile x syndrome

Answer 58

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