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Endocrinology 2 > infertility lecture and tutorial > Flashcards

infertility lecture and tutorial Flashcards

1
Q

what is defined as infertility?

A

failure to achieve a clinical pregnancy after more than 12 months of regular unprotected sexual intercourse

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2
Q

what condition is met with primary infertility?

A

not had a live birth previously

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3
Q

which condition is met in secondary infertility?

A

have had a live birth >12 months previously

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4
Q

what are the three types of infertility causes for a male?

A

pre-testicular
testicular
post-testicular

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5
Q

Give 2 examples of congenital pre-testicular infertility causes

A

Klinefelters 47XXY

Y chromosome deletion

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6
Q

give an example of acquired pre-testicular infertility

A

high prolactin

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7
Q

give a congenital example of congenital testicular infertility

A

cryptorchidism

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8
Q

Give 5 examples of acquired testicular infertility

A
  • infection eg. STDs
  • Immunological - antisperm antibodies
  • vascular (varicocoele)
  • trauma / surgery
  • toxins eg. chemo, drugs, smoking
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9
Q

Give an example of congenital post-testicular infertility?

A

absence of vas deferens in cystic fibrosis

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10
Q

Give 3 examples of post-testicular infertility

A

obstruction
erectile dysfunction
vasectomy

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11
Q

what is cryptorchidism?

A

undescended testis usually stuck in inguinal canal

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12
Q

Give 2 examples of ovarian causes of infertility

A

anovulation

corpus luteum insufficiency

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13
Q

Give 4 examples of uterine causes (unfavourable endometrium) of female infertility

A

chronic endometritis
fibroid
adhesions
congenital malformation

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14
Q

Give 2 examples of cervical causes of female infertility ie. ineffective sperm penetration

A

chronic cervicitis

Immunological (antisperm antibody)

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15
Q

give 3 causes of tubal causes of female infertility

A

infection
endometriosis
trauma

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16
Q

give 2 examples of pelvic causes of infertility

A

endometriosis

adhesions

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17
Q

what is endometriosis?

A

functioning endometrial tissue outside uterus

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18
Q

what is the treatment for endometriosis?

A

oral contraceptive pill, progesterone
laparascopic ablation
hysterectomy
bilateral salpingo-oophorectomy

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19
Q

do fibroids respond to oestrogen?

A

yes

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20
Q

what is a fibroid?

A

benign tumours of myometrium

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21
Q

menstrual pain, menstrual irregularities, deep dyspareunia and infertility are all symptoms of which two diseases?

A

endometriosis and fibroids

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22
Q

what pattern of LH, FSH and testosterone would you see in hyperprolactinaemia in men?

A

LH down
FSH down
testosterone down

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23
Q

what pattern of LH, FSH and testosterone would you see in primary testicular failure?

A

LH up
FSH up
testosterone down

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24
Q

what is failure of GnRH secretion called?

A

hypogonadotrophic hypogonadism

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25
Q

what are the three causes of hypogonadotrophic hypogonadism in both males and females?

A

congenital eg. Kallmann syndrome (anosmic)
acquired due to low BMI and stress
hyperprolactinaemia

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26
Q

name 5 causes of hypopituitarism in males and females

A

tumour, infiltration, apoplexy, surgery, radiation

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27
Q

name 5 causes of hypergonadotrophic hypogonadism in males

A 
klinefelters 47XXY (congenital)
trauma, chemo, radiation, cryptorchidism
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28
Q

list two rare causes of hypogonadism in men

A

androgen receptor deficiency

hyper/hypothyroidism

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29
Q

kallmann syndrome is caused by what?

A

congenital defect of migration of GnRH neurons with olfactory fibres into the hypothalamus

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30
Q

what are the symptoms of kallmann syndrome

A

cryptorchidism
failure of puberty
infertility
no sense of smell

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31
Q

name causes of hyperprolactinaemia

A
  • prolactinoma
  • pituitary stalk compression stopping dopamine reaching pituitary
  • pregnancy and breastfeeding
  • antipsychotics and anti-emetics, oestrogens eg. oral contraceptive pill
  • PCOS
  • hypothyroidism
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32
Q 
tall stature
reduced facial hair
breast development
female-type pubic hair pattern
small penis and testes
infertility
mildly impaired IQ
narrow shoulders
reduced chest hair
wide hips
low bone density

are symptoms of?

A

klinefelter’s syndrome

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33
Q

What initial questions would you ask when taking a history for male infertility?

A 
duration
previous children
pubertal milestones
associated symptoms
medical and surgical history
family history
social history
medications/drugs
34
Q

What would you examine when someone presents with male infertility?

A 
BMI
sexual characteristics
testicular volume
epididymal hardness
presence of vas deferens
other endocrine signs
anosmia
syndromic features
35
Q

what does azospermia mean?

A

no sperm

36
Q

what does oligospermia mean?

A

reduced sperm

37
Q

which core investigations would you carry out when a male presents with infertility?

A

semen analysis, blood tests, microbiology, imaging

38
Q

Which blood tests would you carry out for male infertility?

A 
LH, FSH, PRL
morning fasting testosterone
sex hormone binding globulin (SHBG)
albumin, iron studies
pituitary/thyroid profile
karyotyping
39
Q

which tests would you carry out in the microbiology department for male infertility?

A

urine test

chlamydia swab

40
Q

what imaging would you carry out for male infertility and why?

A

scrotal US/Doppler - check for varicocoele/obstruction, testicular volume

MRI pituitary - (if low LH/FSH, high prolactin)

41
Q

Lifestyle treatment for male infertility includes?

A

optimise BMI
smoking cessation
alcohol reduction/ cessation

42
Q

what specific treatment could be used for hyperprolactinaemia

A

dopamine agonist

43
Q

what would be the treatment for fertility in men

A

gonadotrophins

44
Q

what would be the treatment for infertility in men who don’t require fertility

A

testosterone

45
Q

what would be the treatment if fertility is needed but the sperm can’t get out

A

micro testicular sperm extraction

46
Q

what is primary amenorrhoea

A

no periods past 16 years

47
Q

secondary amenorrhoea is what?

A

periods start then stop for at least 3-6 months

48
Q

amenorrhoea is what?

A

no periods for at least 3-6 months or up to 3 periods a year

49
Q

oligomenorrhoea is what?

A

irregular or infrequent periods >35 day cycles OR 4-9 cycles per year

50
Q

what pattern would you see in premature ovarian insufficiency in terms of LH, FSH and oestradiol?

A

LH up FSH up oestradiol down

51
Q

premature ovarian insufficiency is diagnosed by what level of FSH?

A

> 25 iU/L

52
Q

causes of premature ovarian failure?

A 
autoimmune
genetic eg. fragile X syndrome, turners syndrome
cancer therapy (chemo or radiotherapy)
53
Q

What pattern of FSH, LH and oestradiol would you see in anorexia nervosa induced amenorrhoea?

A

LH, FSH, oestradiol all down

54
Q

name 3 causes of hypergonadotrophic hypogonadism in females

A

premature ovarian insufficiency
PCOS
congenital primary hypogonadism eg. Turners (45X0)

55
Q

name an alternate cause of infertility in females?

A

hyper/hypogonadism

56
Q

How many of the Rotterdam PCOS diagnostic criteria need to be met in order to be diagnosed with PCOS?

A

2 out of 3

57
Q

what are the Rotterdam PCOS diagnostic criteria?

A

oligomenorrhoea or anovulation
clinical/biochemical hyperandrogenism
polycystic ovaries

58
Q

what are clinical signs of hyperandrogenism in females?

A

acne, hirsutism, alopecia

59
Q

Polycystic ovaries are classed by?

A

> or equal to 20 follicles or > or equal to 10ml either ovary

60
Q

when should polycystic ovaries (US) not be used? why?

A

8 years post-menarche because many follicles are common during this time

61
Q

what are the main 4 problems that women with PCOS face?

A

irregular menses/amenorrhoea –> infertility
Increased insulin resistance –> T2DM, gestational DM
Hirsutism
Increased endometrial cancer risk

62
Q

what is the treatment for infertility in PCOS?

A

clomiphene
letrozole
IVF

63
Q

what is the treatment for increased insulin resistance in PCOS?

A

metformin, diet and lifestyle

64
Q

treatment for hirsutism in PCOS?

A

creams, waxing, laser, anti-androgens

65
Q

what is the treatment for increased endometrial cancer risk in PCOS?

A

progesterone courses

66
Q

what initial history would you take in a female presenting with infertility?

A 
duration
previous children
pubertal milestones
breastfeeding?
menstrual history
associated symptoms
medical and surgical history
family history
social history
medications/drugs
67
Q

what would you examine when a female presents with infertility?

A 
BMI
sexual characteristics
hyperandrogenism signs
pelvic examination
other endocrine signs
syndromic features
anosmia
68
Q

what main four investigations would you do in a female with infertility?

A

blood tests, pregnancy test, microbiology, imaging

69
Q

which blood tests should you do on women with infertility?

A 
LH, FSH, PRL
oestradiol, androgens
follicular phase 17-OHP, mid-luteal progesterone
sex hormone binding globulin (SHBG)
albumin, iron studies
pituitary/ thyroid profile
karyotyping
70
Q

which imaging should you do on women with infertility?

A

US (transvaginal)
hysteroalpingogram
MRI pituitary

71
Q

which microbiology tests should you do on a woman with infertility?

A

urine test

chlamydia swab

72
Q

what is Kallmann’s syndrome caused by?

A

congenital failure of migration of GnRH neurons with olfactory fibres into the hypothalamus

73
Q

These symptoms indicate what?

short stature
low hairline
shield chest
wide spaced nipples
short 4th metacarpal
small fingernails
brown nevi
webbed neck
coarctation of aorta
poor breast development
elbow deformity
underdeveloped reproductive tract
amenorrhoea
A

Turner’s syndrome (45X0)

74
Q

how does letrozole work?

A

Letrozole works to induce ovulation by blocking estrogen production, leading to increases in follicle-stimulating hormone (FSH) release

75
Q

How does clomiphene work?

A

blocks oestrogen receptors in hypothlamus, this in turn triggers release of FSH from the anterior pituitary following alterations in GnRH pulsatility.

76
Q

30 year old, BMI 19 kg/m2, amenorrhoea for 6/12, runs daily to help with stress at work, training for London Marathon.

Oestradiol <70pmol/L (undetectable)

LH 0.5 U/L (2 – 14)

FSH 0.8 U/L (1.5 – 10)

Prolactin 300mU/L (100 – 500)

what is the diagnosis?

A

secondary hypogonadism - female athlete triad

physiological response to famine/excessive loss of weight in order to conserve energy.

77
Q

30 year old, BMI 30kg/m2, has gained weight over last 3 years. Oligomenorrhoea for 1 year. Acne and hirsutism particularly problematic over the last year too.

Oestradiol 150pmol/L (50-800)

LH 6 U/L (2 – 14)

FSH 3 U/L (1.5 – 10)

Testosterone 3 nmol/L (<1.8)

what is the diagnosis and treatment?

A

PCOS

weight loss

progesterone because she does have an endometrium - increased cancer risk

anti-androgen - spironolactone for hirsutism

for fertility

  • letrozole
  • clomiphene - antagonist for estrogen receptors in hypothalamus. Increase pulsatility of GnRH and drive ovulation.

IVF

78
Q

40 y old, BMI 24kg/m2, amenorrhoea for 6/12, previously regular periods, no acne, hirsutism, galactorrhoea.

Oestradiol <70pmol/L (undetectable)

LH 30 U/L (2 – 14)

FSH 24 U/L (1.5 – 10)

Prolactin 300mU/L (100 – 500)

what is the diagnosis and treatment?

A

premature ovarian insufficiency

  • premature menopause (LH and FSH are high - trying to drive failing ovaries with no negative feedback)
79
Q

30 yearold, BMI 24kg/m2. Amenorrhoea for 6/12. Previously regular periods. Galactorrhoea. Recent visual disturbance.

Oestradiol <70pmol/L (undetectable)

LH 0.5 U/L (2 – 14)

FSH 0.5 U/L (1.5 – 10)

Prolactin 30, 000mU/L (100 – 500)

what’s the diagnosis? and treatment?

A

prolactinoma

dopamine receptor agonist: cabergoline

80
Q

30 year old, BMI 24kg/m2. Regular periods.

Oestradiol 150pmol/L (50-800)

LH 3 U/L (2 – 14)

FSH 3 U/L (1.5 – 10)

Prolactin 300mU/L (100 – 500)

diagnosis and treatment?

A

male infertility (partner) or something mechanical - blockage in fallopian tubes eg. pelvic inflammatory disease

Investigate partner for sperm count - if that’s normal, look at fallopian tubes. Hysterosalpingogram (dye test, mapping out the tubes and uterus).

Endocrinology 2 (17 decks)

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