5.9 Infertility (tutorial)

Question 1

Case 1:
* 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?

Answer 1

• Secondary hypogonadism
• Acquired hypogonadotrophic hypogonadism
  Likely to be excess exercise, low BMI, stress → secondary hypogonadism
  Hypothalamic amenorrhoea??

Question 2

Case 1:
What treatment would you suggest improving fertility?

Answer 2

• Less exercise, gain weight
• Stress less
  Aromatase inhibitors?

Question 3

Case 2:
* 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?

Answer 3

• PCOS - acne, hirsutism, hyperandrogenism
• BMI obese
• Normogonadotrophic

Question 4

Case 2:
What treatment would you suggest to aid fertility?

Answer 4

• Weight loss
• Clomiphene to induce ovulation - reduces negative feedback from oestradiol on GnRH, LH, FSH levels
• IVF if doesn’t work

Question 5

Why can’t androgen blockers be used during fertility treatment?

Answer 5

Cause foetal abnormalities.

Question 6

How does clomiphene work?

Answer 6

Induces ovulation - selective oestrogen modulator (in this case antagonist).

Question 7

Case 3:
* 40 year old
* BMI 24kg/m²
* Amenorrhoea for 6/12
* Previously regular periods
* No acne, hirsutism or 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?

Answer 7

• Premature ovarian insufficiency
• Primary hypogonadism - hypergonadotrophic hypogonadism

Question 8

Case 3:
Why is this not Turner’s syndrome?

Answer 8

It is secondary amenorrhoea.

Question 9

Case 3:
What treatment would you suggest to aid fertility?

Answer 9

• HRT - oestradiol and progesterone
• IVF - induce ovulation, or egg donor

Question 10

Case 4:
* 30 year old
* 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 is the diagnosis?

Answer 10

• Prolactinoma
• Hyperprolactinaemia → secondary hypogonadism

Question 11

Case 4:
What treatment would you suggest to aid fertility?

Answer 11

• Surgical intervention
• Some medical treatments: dopamine agonists (e.g. cabergoline) but check that they are not teratogenic

Question 12

Case 5:
* 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)

What is the diagnosis?

Answer 12

No clear cause - unknown/no clear cause infertility.

Question 13

Case 5:
What should you investigate in this case?

Answer 13

• Anatomical defects - MRI for uterine problems
• Antisperm Ab
• Corpus luteum insufficiency?
• Enquire about sexual history
• Investigate the partner
• Retest?

Question 14

Case 5:
What treatment would you suggest to aid fertility?

Answer 14

• Depends on further investigations
• Suggest IVF or ICSI - if applicable, dependent on other investigations

Question 15

What is corpus luteum insufficiency? How is it involved in infertility?

Answer 15

Abnormally low progesterone level 3 weeks after onset of menstruation → implantation failure