Investigating infertility Flashcards
(53 cards)
define infertility
inability to conceive after 1-2 years
regular and unprotected sexual intercourse
in absence of any reproductive pathology
pregnancy rate after 1 years/ 2 years?
85%
92%
what’s primary/secondary infertility
primary: no pregnancies with livebirth (70%)
secondary: least one livebirth (30%)
biggest cause of infertility
35% male problems
35% tubal and pelvic pathology
what two things happen to oocytes as a woman ages?
loss of number
loss of quality
other factors affecting fertility
smoking
alcohol (W: 1-2 units/week, men 3-4 units/day)
Obesity (>30)
tight underwear
medication, recreational drugs (NSAIDs inhibit ovulation)
5 (female) reasons for infertility
PCOS Hypogonadotrophic hypogonadism premature ovarian insufficiency hyperprolactinaemia hypo/hyperthyroidism
Rotterdam criteria for PCOS
2/3 of:
- oligo/amenorrhoea
- hyperandrogenism/hyperandrogenaemia
- abnormal USS (12+ follicles per ovary and/or large volume >10mls)
describe PCOS aetiology
increased GnRH pulsatile frequency
increased LH
increased testosterone secretion
decreased SHBG (binds to testos)
arrest in folliculogenesis and ovulation = infertility
also increase in insulin –> more LH, insulin resistance
What are 4 other potential causes of exogenous testosterone increases that can mimic PCOS (and how do you test for them)?
- congenital adrenal hyperplasia (check other androgens: 17-OH progesterone, DHEAS, androstenedione)
- Cushing’s (synachten test)
- Androgen secreting tumour (USS)
- Steroid abuse (history)
Long term risks of PCOS
diabetes type 2
gestational diabetes
CVS and hypertension
endometrial hyperplasia and carcinoma
Investigations for PCOS
elevated free T and FAI (free androgen index)
pelvic USS
SHBG may be low
(+/- fasting glucose, triglycerides, other androgens)
pipelle endometrial biopsy if persistent thick endometrium elevated LH:FSH
Hypogonadotrophic hypogonadism
Symptoms
aka hypothalamic amenorrhoea
low FSH and low oetradiol
problem in the BRAIN
menopausal (hot flushes, vaginal dryness, mood changes)
Causes:
stress
pituitary surgery
inflammation (sarcoidosis, TB)
Sheehan’s (postpartum pituitary necrosis)
Congenital (Kallmann’s syndrome is GnRH absence)
Hypergonadotrophic hypogonadism
Symptoms
aka premature ovarian insufficiency
high FSH, high LH but low oestradiol (because of neg feedback, pituitary thinks needs to work harder so FSH is high)
problem is in the OVARY
Same menopausal symptoms
Idiopathic
Autoimmune (DM, thyroid dysfunction, pernicious anaemia)
Turner’s syndrome
Which cause of infertility may Kallmann’s syndrome be caused by?
Kallmann’s syndrome is GnRH absence.
Hypogonadotrophic hypogonadism
Signs/symptoms associated with hyperprolacinaemia
oligo/amenorrhoea
headaches
bitemporal hemianopia
galactorrhoea
what is diagnostic of hyperprolactinaemia
micro PRL
why does high levels of prolactin cause infertility
prolactin (produced by pituitary) inhibits LH and FSH release so that nothing stimulates the ovaries
usually prolactin is inhibited by dopamine
what is ‘moderate’ hyperprolactinaemia
1000-5000
what can thyroid dysfunction cause
anovulation
HMB (heavy menstrual bleeding)
miscarriage
stillbirth
what can cause tubal damage?
infection
- PID, chlamydia trachomatis is primary pathogen
- pelvic infection: appendicits, septic miscarriage, TB
- Crohn’s
- adhesions post C section
- risk of ectopic surgery
Endometriosis
Hydrosalpinx - fluid is toxic to gametes/embryo
Uterine factors for infertility
fibroids (outgrowth of muscle, not cancerous - depends where it is to interfere with pregnancy. reduce area for implantation)
intrauterine adhesions
congenital anomalites
if there’s a uterine anomaly, what must be done
renal USS
Testicular dysfunction and failure of spermatogenesis caused by:
testicular torsion cryptochidism infection (recent UTI, mumps) neoplasm, chemotherapy Klinefelter's 47 XXY
