Reproductive System Week 7

Question 1

What is coitus?

Answer 1

The act of sexual intercourse that results in the deposition of sperms inside the vagina at the level of the cervix

Question 2

What happens to the sperm after ejaculation at the cervix?

Answer 2

A proportion of sperm enters the uterus and reaches the uterine tubes where they may encounter an ovum released from the ovary

Question 3

What is conception?

Answer 3

Fertilisation of the ovum by a sperm and the subsequent establishment of pregnancy

Question 4

What are the stages of sexual excitement?

Answer 4

Excitement phase, plateau phase, orgasmic phase and resolution phase

Question 5

What happens during sexual excitement (broadly)?

Answer 5

Genital and systemic changes in both sexes

Question 6

Describe the male sexual response

Answer 6

Excitement phase -

• sensory and psychological stimulation–> limbic system
• activation of sacral parasympathetic neurones
• inhibition of thoracolumbar sympathetic neurones
• ACh -> M3 receptors on endothelial cells –> more intracellular Calcium –> activation of eNOS –> NO production (vasodilator)
• Arteriolar vasodilation in corpus cavernosa
• increased penile blood flow
• penile filling (latency)
• penile tumescence (erection - reversible) -
• testes begin to elevate and engorge
• scrotal skin thickens and tenses

Plateau phase
Activation of sacrospinous reflex
Contraction of bulbospongiosus ischiocavernosus (compresses crus penis and
impedes venous return) → venous engorgement
Rise in intracavernosus pressure → decreased arterial inflow Stimulation of secretionfrom accessory glands:
Cowper’s and Littre’s glands
• Lubricate distal urethra
• Neutralise acidic urine in urethra
• 5% of ejaculate
Corona may become further engorged
Testes become completely engorged and elevated
Loss of erection unlikely

Orgasm:
Emission:
Simulation of thoracolumbar sympathetic reflex
Contraction of smooth muscle in ductus deferens, ampulla, seminal
vesicle and prostate
Internal and external urethral sphincters contract - prevents retrograde ejaculation
Semen is pooled in urethral bulb
Contractions of ampulla of vas deferens
Ejaculation:
Spinal reflex (with cortical control)
Sympathetic Nervous System (L1, L2)
Contraction of glands and ducts (smooth muscle)
Internal urethral sphincter contracts
Filling of the internal urethra stimulates pudendal nerve
–>contractions of the genital organs, the ischiocavernosus and bulbocavernosus muscles –>expulsion of semen
External urethral sphincter relaxes
Contractions of penile urethra
Contraction of anal sphincter

Resolution:
Activation of thoracolumbar sympathetic pathway
Contraction of arteriolar smooth muscle in corpora cavernosa Increased venous return
Detumescence and flaccidity - erection loss
Refractory period
Testes descend and return to unstimulated size
Scrotum thins and resumes wrinkled appearance

Question 7

Describe the female sexual response

Answer 7

Excitement:
Same neuronal responses as male - parasympathetic from sacral plexus
Vaginal lubrication begins (due to vasocongestion)
Inner 2/3 of vagina lengthen and expand
Clitoris engorges with blood
Uterus elevates
Increase in muscle tone, heart rate, and BP
Breast size increases
Nipple becomes erect
Veins become more distinct

Plateau:
Further increase in muscle tone, heart rate and BP
Labia minora deepen in color
Clitoris withdraws under its hood
Bartholin’s gland secretion lubricates vestibule for entry of penis
Orgasmic platform forms in lower 1/3 of vagina - rhythmic contractions
Inner 2/3 of vagina fully extended
Breast same as orgasm phase

Orgasm:
Orgasmic platform (outer 1/3 of vagina) contracts rhythmically 3-15
times
Uterus contracts starting at fundus and moving down, anal sphincter contracts
Clitoris remains retracted under hood
No refractory period - multiple orgasms possible
Greater size increase of breast
Areola increases in size and causes nipple to seem less erect
Sex flush may appear on breasts and upper abdomen

Resolution:
Clitoris descends and engorgement subsides
Labia return to unaroused size and color
Uterus descends to unaroused position
Vagina shortens and narrows back to unaroused state
Breast - areola detumescence nipple appears more erect - disappearance of sex flush, return to unaroused size of breast

Question 8

What is the G spot?

Answer 8

Grafenberg spot (Ernest Grafenberg, a
gynaecologist who first publicised G spot in
1950s)
Area of erotic sensitivity located along the
anterior wall of the vagina.
Some women are able to experience orgasm and possibly ejaculation from G spot stimulation.
– G spot tissue is similar to male prostate;
therefore, fluid may be similar to prostatic
component of semen.
Supported by research that showed
presence of enzyme in female ejaculate
characteristic of prostate secretions
Orgasm from G spot stimulation is same as
orgasm from clitoral stimulation, though intensity
may vary depending on the method of
stimulation.

Question 9

What happens to the female sexual response with age?

Answer 9

Some women report reduced desire
Reduced vasocongestion response, causing reduced
vaginal lubrication
Vaginal and urethral tissue lose elasticity
Length and width of vagina decrease; reduced expansile
ability of inner vagina during arousal
Number of orgasmic contractions is often reduced
More rapid resolution

Question 10

What is a normal amount to be having sex?

Answer 10

Normal varies from person to person
10-20% of married couples report engaging in sexual activity a couple of times per year
30% report engaging in sexual activity 2-3 times per week

Question 11

What is the most common type of sexual dysfunction?

Answer 11

Desire - increasing incidence

Question 12

Name some sexual dysfunctions to do with desire

Answer 12

Hypoactivity
Aversion - revulsion or fear of one or more aspects of sex - often a result of assault or abuse
Hyperactive
Nymphomaniac
Kluver Bucci syndrome - bilateral medial temporal lobe lesions from cerebral metastases or head injury etc. –> hyperphagia, hypersexuality, hyperorality, visual agnosia and docility

Question 13

Describe sexual dysfunctions involving arousal

Answer 13

Female - persistent, recurrent inability to attain or maintain lubrication-swelling response - -> lack of lubrication (especially in menopause)
Male - impotence - psychological (descending inhibition of spinal reflexes), tears in fibrous tissue of corpora cavernosa, vascular (atherosclerosis, diabetes), drugs (alcohol, antihypertensives - B blockers and diuretics)

Question 14

Describe the mechanism of action of viagra

Answer 14

Inhibits cGMP breakdown in corpus cavernosum
Increases NO stimulated vasodilation
Increases penile blood flow –> erection

Question 15

What is an alternative treatment to viagra?

Answer 15

Penile implant - reservoir of fluid - pump up by squeezing bulb in scrotum

Question 16

Describe the properties of normal semen

Answer 16

2-4ml
20-200x10^6 sperm per ml
Total sperm per ejaculate >40 X10^6
>60% sperm swimming forward vigorously
<30% abnormal morphology
Liquefaction within 1 hour

Question 17

When is semen described as abnormal?

Answer 17

< 20x10^6 sperm per ml (oligozoospermia)

Or doesnt meet the other criteria for ‘normal’

Question 18

What are some sperm morphological defects?

Answer 18

Giant
Micro sperm
Double head
Double body
Long head
Rough head
Abnormal middle piece

Question 19

Describe the glandular components of semen

Answer 19

Bulbourethral glands - 5% volume

• alkaline fluid
• mucous lubricants the tip of the penis and urethral lining

Seminal vesicles - 60% of volume

• alkaline fluid - neutralises the acid in male urethra and female reproductive tract
• fructose (ATP production), prostaglandins (increase sperm motility, increase female genital smooth muscle contractions), clotting factors (semenogelin)

Prostate- 25% volume

• milky, slightly acidic fluid
• proteolytic enzymes (PSA, pepsinogen - breakdown clotting factors from seminal vesicles, reliquify semen in 10-20 mins)
• citric acid (ATP production), acid phosphatase

Question 20

When is the female reproductive tract a hospitable environment for fertilisation and implantation?

Answer 20

Days 14-28 - uterine secretory phase - oestrogen and progesterone

Question 21

How does the female reproductive tract aid in getting the semen to the site of fertilisation?

Answer 21

Site of fertilisation - ampulla
Site of deposition - cervix
Oxytocin stimulates uterine contractions

Question 22

Describe how the cervical mucous changes over the uterine cycle

Answer 22

Days 7-14 - oestrogen only - abundant, clear non-viscous cervical mucous
Days 14-28 - oestrogen and progesterone - thick, sticky mucous plug - prevents infection from reaching uterus

Question 23

Describe the nuclear maturation of the oocyte

Answer 23

Oocyte undergoes meiosis I
Nuclear membrane of oocyte disappears
First polar body separates and enters the perivitelline space
Second meiotic division takes place - stops in metaphase II

Question 24

Describe the cytoplasmic maturation of the oocyte

Answer 24

Mitochondria dispersed throughout the cytoplasm
Endoplasmic reticulum - accumulates in oocyte cortex, protein and lipid synthesis creates cortical granules
The granules are initially dispersed throughout the cytoplasm but become cortical as the oocyte matures
Lipid droplets provide energy for meiosis, maturation, fertilisation and early embryo development
Cytoskeleton microfilaments migrate towards oocyte cortex

Question 25

How many sperm are required to get pregnant?

Answer 25

Average 200-300 million per ejaculate 300 reach fertilisation site 299+ sacrificed to disperse the zona pellucida 1 sperm required for fertilisation

Question 26

How long do sperm survive in the female genital tract?

Answer 26

Up to 5 days

Question 27

How long do oocytes survive?

Answer 27

6-24 hours before phagocytosis

Question 28

When is the fertile period?

Answer 28

Sperm deposition can be up to 3 days prior to ovulation or on the day of ovulation The oocyte takes 3-4 days to travel from the ovary to the body of the uterus (cilia and Fallopian tube peristalsis) Fertilisation is in the Fallopian tube

Question 29

How long does it take the oocyte to travel to the uterus?

Answer 29

The oocyte takes 3-4 days to travel from the ovary to the body of the uterus (cilia and Fallopian tube peristalsis)

Question 30

Describe how sperm further mature in the female genital tract before fertilisation can occur

Answer 30

Sperm undergo further maturation for 6-8 hours after deposition in the female genital tract (capacitation) Sperm cell membrane changes in the female genital tract environment to allow fusion with the oocyte cell surface - removal of protein coat and acrosomal enzymes are exposed which can digest through the zona pellucida Tail movement changes from beat to whip-like action (3mm/hour) Sperm need to penetrate corona radiata (follicular cells) And zona pellucida (glycoprotein membrane) of the ovum

Question 31

Describe how the acrosome reaction begins and what it involves

Answer 31

When sperm contacts the corona radiata has an intact acrosome Pushes through the corona radiata using the force produced by the tail Proteins on sperm head bind to ZP3 proteins of zona pellucida Triggers acrosome reaction: Key signalling mechanism nvolves intracellular calcium Acrosomal enzymes digest path through ZP One sperm penetrates --> fusion of plasma membranes of oocyte and sperm Sperm moves into cytoplasm --> zygote Cortical reaction prevents polyspermy

Question 32

Describe the plasma membrane of the oocyte

Answer 32

Can be divided into two major regions: - the part that directly overlies the metaphase chromosomes is smooth and devoid of microvilli - the rest is rich in micro villas protrusions - where sperm bind and fuse

Question 33

Describe the fast block and slow block to polyspermy

Answer 33

Fast block: Electrical change in oocyte membrane Na channels open (resting potential is -75mV, fertilisation potential is +20mV) Wave of depolarisation starts at point of entry of sperm and propagates across the cytoplasm Slow block: Calcium released from endoplasmic reticulum induces local exocytosis of cortical granules Granules release enzymes to stimulate adjacent cortical granules to undergo exocytosis Wave of exocytosis occurs around oocyte in 3 dimensions from original point of entry of sperm

Question 34

What is syngamy?

Answer 34

The union of male and female pronuclei to form a diploid zygote nucleus (46 chromosomes) Oocyte completes meiosis II, expels second polar body, and the male and female pronuclei migrate towards each other to fuse

Question 35

What is polyploidy and how can it occur?

Answer 35

Embryo contains three or more pronuclei Entry of more than one sperm or failure of extrusion of second polar body

Question 36

Describe cleavage

Answer 36

A series of rapid mitotic divisions and metabolic changes for upcoming cell division and embryogenesis Increasing number of cells (16-32 blastomeres) of decreasing size - no increase in size of fertilised ovum Totipotency - each cell has the capacity to become anything (can become an entire individual)

Question 37

What's the difference between monozygotic and dizygotic twins?

Answer 37

Monozygotic - during cleavage the totipotent cells become divided into 2 separate independent cell masses (25-35% of twins follow separation after first cleavage) Dizygotic - 2 eggs ovulate, 2 eggs fertilised

Question 38

Why is cleavage important?

Answer 38

Generation of a large number of cells that can undergo differentiation and gastrulation to form organs Increase in the nuclear/cytoplasmic ratio - one nucleus couldn't transcribe sufficient mRNA to support the entire zygote, No G1 (duplication of organelles and cytosol) or G2 (protein synthesis) stages in cleavage, cleavage is asynchronous (not all blastomeres divide at the same time)

Question 39

Describe compaction

Answer 39

8 cell stage | Blastomeres undergo polarisation and form tight junctions to create inner embryo environment

Question 40

What is a morula?

Answer 40

16 blastomere stage 3-4 days following fertilisation Embryo passes into uterus

Question 41

What is ectopic pregnancy and what are the clinical consequences?

Answer 41

Failure of morula to enter the uterus Implantation in Fallopian tube, ovary or peritoneal cavity Risk of maternal haemorrhage Embryo is non-viable

Question 42

Describe the blastocyst stage

Answer 42

5 days after fertilisation Fluid-filled cavity develops in morula (blastocoele) --> blastocyst Loss of totipotency Inner cell mass (embryoblast) --> embryo Outer cell mass (trophoblast) --> contributes to formation of placenta and produces hCG

Question 43

Describe the hatching process

Answer 43

Local digestion of zona pellucida by enzyme produced in trophoblast cells Opposite the inner cell mass (minimises risk of damage to embryo) After hatching, blastocyst begins process of implantation

Question 44

Describe implantation

Answer 44

Zygote to blastocyst - days 14-21 of uterine cycle Progesterone priming of endometrium Conceptus nourished in intrauterine fluid - 2-3days 'floating' in uterus Trophoblast overlying inner cell mass is sticky - adheres to endometrium Implantation commences 6 days after ovulation

Question 45

What proportion of couples who have unprotected sex could be expected to conceive within a year?

Answer 45

75%

Question 46

In Western Europe populations, what proportion of primary infertility is due to problems with the male partner?

Answer 46

30%

Question 47

List the possible points in the female reproductive system where problems may lead to infertility. Write beside each the approximate proportions of women in which each type of problem is identified as the cause

Answer 47

Failure to ovulate - 28% Fallopian tube problems - 22% Uterine problems - 11% Cervical problems - 3%

Question 48

What are the likeliest causes of erectile dysfunction in young men?

Answer 48

Psychological Endocrine (e.g., diabetes) Neurological Alcohol

Question 49

Which hormone provides evidence that ovulation has occurred, when and from where should you measure it?

Answer 49

``` Progesterone Day 21 (at peak of progesterone curve) in blood ```

Question 50

Why is it useful to keep a daily record of body temperature on rising in the morning? Why does the temperature have to be taken at the same time each day?

Answer 50

Progesterone elevates basal temperature | Circadian rhythm of body temperature will confuse results if not same time of day

Question 51

What are the clinical signs of hyperprolactinaemia, what are the consequences of this condition for fertility and how can it be treated?

Answer 51

Production of small quantities of milk Infertility Bromocryptine - dopamine agonist (prolactin inhibitory hormone)

Question 52

How, in principle, might you test whether uterine tubes are patent?

Answer 52

Passage of radio-opaque dye from uterine cavity, hysterosalpingography

Question 53

What particular feature in a patient’s history might lead you to suspect that the uterine tubes could be blocked?

Answer 53

Previous pelvic infection

Question 54

What properties of cervical mucus facilitate sperm survival and transport?

Answer 54

Alkalinity, lowered viscosity

Question 55

How might you establish whether cervical sperm transport is disturbed?

Answer 55

Post coital test – collect cervical mucus soon after copulation

Question 56

How in principle would you set about inducing ovulation in a woman whose cycles are anovulatory? Suggest which types of drugs or hormones might be used and why

Answer 56

Use an anti-oestrogen to reduce inhibition of FSH & LH e.g., clomiphene given for a few days prior to expected time of ovulation

Question 57

In polycystic ovarian syndrome (PCOS), exposure of follicles to androgens may lead to inhibition of FSH, but not LH secretion. From what you know of the control of gonadotrophin secretion, by what mechanism might FSH secretion be inhibited selectively? Why might there be no LH surges in this condition?

Answer 57

Follicles may still secrete inhibin which selectively inhibits FSH, thus reducing FSH in respect to LH (hence, ratio changed) Androgens may suppress LH surges (consider the role of testosterone in the male which inhibits LH release from the pituitary).

Question 58

What features of excess androgens may be present in PCOS?

Answer 58

hirsutism (which can be blocked by anti-androgen therapy) oily skin / acne

Question 59

Why is there an increased risk of endometrial malignancy in prolonged and untreated PCOS?

Answer 59

Due to sustained oestrogen stimulation of the endometrium

Question 60

What effect does progesterone have on the HPG axis before and after ovulation?

Answer 60

Moderate/high dose - enhances the negative feedback of oestrogen before ovulation, reduce LH and FSH secretion - inhibits the positive feedback of oestrogen at ovulation --> no LH surge --> no ovulation At lower doses - does not inhibit the LH surge - ovulation still likely - however thickens cervical mucous - harder for sperm to penetrate

Question 61

Describe some natural methods of contraception and their advantages and disadvantages

Answer 61

Fertility awareness methods - use of fertility indicators to identify fertile points of menstrual cycle - cervical secretions (large amounts of thin, watery mucous when fertile), basal body temperature (progesterone increases it), length of menstrual cycle: Lactational amenorrhoea method - breastfeeding delays the return of ovulation following childbirth - only effective for 6 months following birth - suppresses GnRH release (doesnt work if also using bottle) Advantages - no hormones, no contraindications Disadvantages - not as effective, unreliable

Question 62

Describe some barrier methods of contraception and their advantages and disadvantages

Answer 62

Male/female condoms - physical barrier, prevents entrance of sperm into cervix: Advantages - Can help prevent against STIs Disadvantages - male condoms - sensitivity/allergy to latex Female condoms - not widely available Female diaphragm/cap - physical barrier, prevents entry of sperm into cervix, also used with spermicide so additional chemical barrier: Advantages - Can be inserted anytime before intercourse Disadvantages - Need to use with spermicide (can cause a local reaction)

Question 63

Describe some prevention of ovulation methods of contraception and their advantages and disadvantages

Answer 63

Combined oral contraceptive pill - pill containing both oestrogen and progestogen (synthetic progesterone) - taken for either 21 days followed by 7 day break or 21 days followed by 7 days of dummy pill: principal action - prevents ovulation secondary actions - reduces endometrial sensitivity to inhibit implantation, thickens cervical mucous to inhibit penetration of sperm Advantages - can relieve menstrual disorders, reduces risk of ovarian cysts and cancer Disadvantages - user dependent (same time everyday), side effects (breakthrough bleeding, breast tenderness, mood disturbance), increased risk of venous thromboembolism and myocardial infarction, many contraindications (previous stroke etc.) Progesterone depot - progestogen - administered via SC or IM injection which is slowly released into circulation - can last between 8-13 weeks Principal action - prevents ovulation Secondary actions - reduces endometrial sensitivity to inhibit implantation, thickens cervical mucous to inhibit penetration of sperm Advantages - convenient (no pill everyday), can also relieve menstrual disorders Disadvantages - altered and irregular bleeding is common, delayed return of fertility for up to a year after stopping, not quickly reversible, small loss of bone mineral density and possible increase in fracture risk (not for <18s) Progesterone implant - progestogen containing 4cm rod - inserted subdermally int he upper arm - can last up to 3 years Principal action - prevents ovulation Secondary actions - reduces endometrial sensitivity to inhibit implantation, thickens cervical mucous to inhibit penetration of sperm Advantages - long duration of action, convenient, can also relieve menstrual disorders Disadvantages - small procedure required to fit and remove the implant, local adverse effects can occur (migration, infection), can cause changes in bleeding pattern

Question 64

Describe inhibition of sperm transport methods of contraception

Answer 64

Progesterone only pill - pill containing progestogen only at a low dose, taken everyday Principal action - thickens cervical mucous, making it impenetrable to sperm Ovulation usually not prevented Advantages - can be used where the COCP is contraindicated Disadvantages - menstrual problems are common, must be taken at the same time everyday (error for forgotten pills is only 3 hours late)

Question 65

Describe inhibition of implantation methods of contraception

Answer 65

Intrauterine system - small plastic device containing slow release progestogen - placed in uterus - can last between 3-5 years Principal action - reduces endometrial proliferation and prevents implantation Secondary actions - thickens cervical mucous Ovulation usually not prevented Advantages - convenient, long duration of action, can also relieve menstrual disorders Disadvantages - Insertion may be unpleasant, IUS displacement/expulsion may occur, menstrual irregularity common in the first 6 months, risk of uterine perforation is ~2/1000 insertions Intrauterine device - small device made of plastic with added copper that is placed in the uterus - lasts between 5-10 years Principal action - copper is toxic to sperm and ovum - prevents fertilisation Secondary actions - copper causes endometrial inflammatory reaction - prevents implantation, reduces penetration of sperm due to effect of copper on cervical mucous Advantages - convenient, long duration of action, can also be used as emergency contraception (up to 5 days after unprotected intercourse) Disadvantages - insertion may be unpleasant, IUD displacement/expulsion may occur, periods may be heavier, longer or more painful, risk of uterine perforation is ~2/1000 insertions

Question 66

Describe sterilisation methods of contraception

Answer 66

Male - vasectomy - vas deferens interrupted to prevent sperm from entering ejaculate - performed under LA - confirm success by post-operative semen analysis approx 12-16 weeks following surgery Female - tubal ligation/clipping - Fallopian tubes cut or blocked to stop the ovum from travelling from ovary to uterus - done under LA or GA Advantages - permanent, no hormonal side effects Disadvantages - male failure rate 1/2000, female failure rate 2-5/1000, should not be chosen if any doubt about having children in the future - not widely reversible

Question 67

What is infertility?

Answer 67

Failure of conception in a couple having regular, unprotected coitus for one year

Question 68

What is primary infertility?

Answer 68

No previous pregnancy

Question 69

What is secondary infertility?

Answer 69

Previous pregnancy, successful or not

Question 70

How many people have trouble conceiving in the UK?

Answer 70

1/7 couples - 3.5 million people in the UK

Question 71

What history would you take from a female with fertility issues?

Answer 71

``` Age Duration of infertility Menstrual cycle - length and predictability of cycle, age of menarche Tubal or pelvic surgery PID Menorrhagia Pelvic pain Sexual history - any infections ```

Question 72

What history would you take from a male with fertility issues?

Answer 72

General health Alcohol/smoking Previous surgery/injury to the testes Drug history Sexual history and previous infections (STIs) Sexual dysfunction (erectile dysfunction etc.)

Question 73

What would you include in your examination of a patient with fertility issues?

Answer 73

BMI Signs of secondary sexual characteristics Galatorrhoea (spontaneous flow of milk from breast unassociated with child birth)- hyperprolactinaemia Pelvic examination - feel for structural abnormalities Do not usually perform male examination in absence of relevant history - potentially look at testicular size and check for descent

Question 74

What are the statistics relating to the aetiology of infertility?

Answer 74

``` Male factors - 30% Ovulation disorders - 25% Tubal damage - 20% Uterine or peritoneal disease - <10% Other factors including unexplained infertility - 25% ```

Question 75

What are the most common male factors involved in infertility?

Answer 75

Idiopathic oligospermia (most common) Varicocoele - bag of worms - increased temperature causes damage to sperm Abnormal sperm production- e.g. testicular disease Hypothalamic/ pituitary dysfunction - high levels of prolactin inhibit production of GnRH Ductal obstruction (post-infective epididymitis, post-vasectomy) Failure to deliver sperm to the vagina (hypospadias, impotence)

Question 76

How can ovulatory disorders be classified?

Answer 76

Group 1 - hypothalamic-pituitary failure - hypogonadotrophic hypogonadism - not enough GnRH or acquired (weight loss, anorexia), hyperprolactinaemia Group 2 - hypothalamic-pituitary-ovarian dysfunction - eugonadotrophic - polycystic ovarian syndrome, congenital adrenal hyperplasia - anovulation Group 3 - ovarian failure - hypergonadotrophic hypogonadism - early menopause, turner syndrome, cancer/chemo/radiotherapy, surgery

Question 77

Describe polycystic ovary syndrome

Answer 77

Syndrome consisting of polycystic ovaries and systemic features resulting from elevated androgens Unknown pathophysiology but appears to have a genetic component - increased androgen secretion - raised LH/FSH ratio - follicles secrete inhibin - insulin resistance - multiple small ovarian cysts - lots of follicles arrested at early antral stage - anovulation - amenorrhoea or oligomenorrhoea ``` Clinical features: - hirsuitism - acne - obesity - male-pattern baldness - oligomenorrhoea - psychological history - mood swings, depression and anxiety Rotterdam diagnostic criteria: 2/3 of the following: 12 or more follicles on ultrasound Oligoovulation or anovulation Clinical and/or biochemical signs of hyperandrogenism Exclusion of other causes of androgen excess ```

Question 78

What are the common causes of tubal damage?

Answer 78

``` Past pelvic infection e.g. Chlamydia Previous pregnancies e.g. Ectopic Pelvic surgery Endometriosis Mullerian developmental anomaly ```

Question 79

What are the causes of uterine or peritoneal disease?

Answer 79

Endometriosis Ashermans syndrome - adhesions or fibrosis of endometrium Uterine fibroids - myometrium benign tumour Cervical stenosis - trauma, genetic, STIs, cervical cancer Cervical hostility - due to infection or female sperm antibodies - acidic cervix

Question 80

Describe endometriosis

Answer 80

``` Presence of endometrial tissue in sites other than the uterine cavity - most commonly in the pelvic cavity 10-15% of women Clinical features: - dysmenorrhea -dyspaureunia - painful sex - chronic pelvic pain - infertility ``` Laparoscopy Management - contraceptive pill if dont want pregnancy, NSAIDs, IVF if want to conceive

Question 81

What are some other factors involved in infertility?

Answer 81

Unexplained infertility Poorly controlled diabetes - common in Leicestershire and in polycystic ovary syndrome Coital problems Multifactorial - 5-10% of cases

Question 82

Who should be referred for further investigations regarding infertility?

Answer 82

A woman of reproductive age who hasnt conceived after 1 year of unprotected vaginal sexual intercourse - in the absence of any known cause of infertility A woman of reproductive age who is using artificial insemination to conceive with either a partner or donor sperm - who has not conceived after 6 cycles of treatment - in the absence of any known cause of infertility Early referral for : Women >36 years Known clinical cause of infertility or a history of predisposing factors for infertility

Question 83

What investigations are used for females with fertility issues?

Answer 83

``` Follicular phase LH, FSH (day 2) Luteal phase progesterone (day 21) if ovulating regularly Prolactin, androgens, TFTs Cervical smear Pelvic USS Test of tubal patency ```

Question 84

What investigations are used for males with fertility issues?

Answer 84

Sperm analysis - motility, morphology, count Antisperm antibodies - if testicular blood barrier is dysfunctional e.g. Due to trauma FSH/LH/testosterone USS Karyotype Cystic fibrosis - congenital absence of ductus deferens Testicular biopsy

Question 85

What are the figures for normal semen?

Answer 85

``` Volume >2ml PH 7.2-7.8 Sperm count >20 million per ml Motility >50% Morphology >50% ```

Question 86

Describe the management of fertility issues

Answer 86

Depends on the cause ``` Induction of ovulation: Clomifene citrate - reduces negative feedback of oestrogen on hypothalamus Gonadotropins GnRH agonists Weight loss/gain Dopamine agonists Ovum donation ``` Tubal occlusion: Tubal surgery (re-anastomosis) Assisted conception ``` Male factors: Artificial insemination by donor Intracytoplasmic sperm injection GnRH agonist Dopamine agonist ```