DIP Episode 493 - The Super Clutch Infertility Podcast (for Step 1-3)

Welcome. This is Divine. This is episode 493 of the Divine Intervention Podcast. And to these podcasts we're going to be addressing the topic of infertility. In fact I think I want to call this the extremely clutch infertility podcast. Honestly this material can be tested in so many ways on the USMLE exams. So I would not mess around with this if I were you. Today I'm going to be spending most of the time on vignettes. Like probably like 20 or more vignettes of just many different ways to test infertility. So please this is something I want to pay attention to. This is super high yield if you're taking step one, step two, or step three. Simple as that. Alright, so let's begin. So before we begin with the vignettes, just get a few quick things out of the way. First thing I'm going to say is typically we're going to see a person is infertile. When they've tried for a year, so 12 months, you know, contraceptive free. They've been trying to learn sexual intercourse, been treating intercourse, you know, pretty regular intervolts. And they're still not able to conceive. That's going to be considered to be infertility. And again we usually don't worry on the USMLE exam about treating until it's a year or more. There's 13 people where we actually begin to worry after like six months that we kind of need to start on this treatment. It's usually the big one. Again, they're mini criteria, but again, let's focus on what's high yield in this podcast.

The big one is if you're if you've tried for over, if you're if you're over age 35. So you see that man for six months, I've not been able to conceive on you over 35. We're generally going to start treating at that point. Now another thing I'm going to say is that many resources and many people honestly, persevered on the work of infertility. But in my experience, I found out to have found that to have very limited yield for the USMLE exams. So I'm actually not going to spend any time on those. Many times when they give you a cue stem on infertility and they're looking for a diagnostic test, the question stem will give you clues as to the cause of the infertility. So you want to pick a diagnostic test or a treatment step that addresses the cause of their infertility. That's what I'm going to say. This is normally trying to cup out. This is just me telling you what makes the most sense for your exams. So you don't spend your time memorizing or learning a ton of stuff that you don't really need. Okay. So my very first question. What is the biggest first factor for infertility? Well, the biggest risk factor for infertility is going to be each. As many of you know, the USMLE is the love to test risk factors these days. The biggest risk factor, very high yield for infertility is each. Okay. Now, what if they give you, what is the biggest risk factor for infertility like in a mail? And you don't see age as an answer.

If you don't see age as an answer, then I want you to pick the answer that says, Semen quality. If a month's Semen is not, you know, doesn't work right. You know, doesn't move right. Doesn't have the right qualities, right characteristics. Then it may be very difficult for that sperm to do its job and fertilize it and egg. Okay. So let's begin to go into something. So what if they give you a question about a lady that's four foot three inches tall. And they tell you that, you know, she's 23 years old. She has been married, having intercourse with a husband and she's not being able to conceive. And then you're told that she has a cranky history of a low extraneous loadication. If you see something like this, I hope you're saying, oh, divine, this is Turner syndrome. So remember, in Turner syndrome, you're 45 X. So have a bunch of problems. They can have a quotation of the other. That's why this loadication is there. They can have bicospediotic valves that can cause the odics to no say. Usually like in the 30s, 40s, they can have many different issues, right? They can have a horseshoe kidney. They can have a bunch of things, right? So what's the cause of the infertility? The cause of the infertility is they have streak ovaries. They have streak ovaries. Again, can these people deliver half kids? Yeah, they can, but it's pretty rare. It's not common. At least they will need it with some degree of assistance.

But basically these people have a high pulmonary disease because they have streak ovaries. So because they're going to not working right, there's no negative feedback. So their FSHHGNR is elevated. So these people almost have like a hypergonnaidotropic hypogonnaidism. Some silvergonnaidotropins are high. That's why it's called hypergonnaidotropic. Or you can see friends at the endgame is called it like hypergonnaidotropic amenorrhea. Just something I want to keep at the back of your mind, for example. Okay. Now, what if they give you a question about a lady? And they tell you that she's 27 years old and BMI is 34. And that she has been unable to have kids despite trying for a year. And then you're told that she, her human guinea once is elevated. And they tell you that you see like a velvety lesion around her neck and whatnot. And she also tells you that her mency, she has like very heavy mency, every three or four months. When you see something like this, that's PCOS straight up. It's per se as PCOS. Remember, people that have PCOS, the big problem is an ovulation. Remember, if you look at the menstrual cycle, you know, your eggs kind of germinate, germinate, germinate. And then, LH search happens and then boom, your ovulate. After your ovulate, then the egg, the sperm, comes after that egg. So in PCOS, these people have an ovulation. And this is what you can tell from this QSTEM is that, wow, this person has irregular menses. So they have an ovulation.

They're not ovulating frequently enough. They're not ovulating properly. That can cause infertility. Right? Although one thing I think you want to keep at the back of your mind with PCOS is that most people that have, many people that have PCOS, their hormone levels are generally normal. Okay, I'm going to say that again, many people that have PCOS now, hormone levels are generally normal. So if you remember for the Turner Syndrome case, I talked about, I said, oh, that this is going to be a case of hyper-gonadotropic imminoria. People that have PCOS is more a case of normal-gonadotropic imminoria. Normal-gonadotropic imminoria. So they are going to the tropic levels. Generally tend to be pretty normal. Just don't think you want to keep in mind when you're exempt. Okay, and then the third, the next thing I mean, this, our discusses again, why, why we, I mean, this is a normal physiologic phenomenon. But it's something I want to make sure you understand. Why may a woman, you know, especially for the first few months, again, maybe before I say this, put on a disclaimer, none of this is medical advice, just saying this for educational purposes. FYI, right? But why may a woman be in fertile? For the first few weeks, first few months after she delivers a baby. Well, the thing is, on your exams, you can actually supply an answer that says, hyper-gonadotropic, hyper-gonadism. And you wonder, divine, come on, like, how is it hyper-gonadotropic hyper-gonadism?

What's the length there? Well, let me explain. The length there is that when you're breastfeeding, if you're breastfeeding, right? Even when making tons of prolactin. Prolactin is a very powerful inhibitor of GNRH. If you give it GNRH, then you have less GNRH, you have less FSHH, right? And you ultimately have, your gonads not being stimulated, right? So that then calls you to have, so because everything in the pathway is low, right? That's an example of a hyper-gonadotropic, hyper-gonadism, or, again, it can be called hyper-gonadotropic, immunaria, right? And so you may see like this prolactin relationship, like, honestly, there are so many ways they can throw in prolactin as the cause of a person's infertility on your exams. I'm telling you, like, prolactin is like an easy target for infertility questions. Like, for example, they can give you a question about a person that is infertile and they're taking drugs for angina. Well, think of a drug like Vera Pameil. Vera Pameil is a non-dihydropyidine calcium channel blocker. It's a class IV anti-aridmic. It can actually cause an increase in prolactin secretion. That can cause immunaria. Or, you can give you a question about a person that, you know, was hearing voices a few years ago, but now they are pretty stable. They don't have those episodes anymore. And they are chronic pharmacotherapy. That's going to be an anti-psychotic.

Remember, anti-psychotics is especially respiratory don't through that tuberine from developed pathway when you block the dopamine due to receptor. That's going to cause you to meet tons and tons and tons of prolactin. Tons and tons and tons of what? Pro-lactin. That's pretty high you to know for, for example. Or, you can give you a question about a person that has diabetes, right? And it's really the mean, this person that has diabetes, they have gastroparesis. And they've been on pharmacotherapy and then now they're infertile, right? Think of metoclopromide. Remember, one of the drugs you use for diabetes gastroparesis and metoclopromide? Metoclopromide is pretty much an anti-psychotic. It's a de-tour receptor blocker. If you block those de-tour receptors through that tuberine from developed pathway, which is high you to know by the way, your production is going to rise. It's going to show down your GNRH. You're going to have that hypo-gonadotropic hypo-gonadism. Or, they can give you a question about a person, you know, that, you know, has like chronic abdominal pain, you measure their calcium. It's like 13.9. It's like pretty high. And then they tell you that, you know, the person has a family history of some other member having like chronic hypo-glycemic episodes. When you see stuff like that, that's MEN1. Remember, MEN1 is an Odomodominant disorder. And it has like three findings, right? The where memories with parapanpid.

So they have cryotheraic problems like primary hyperthyroidism, which I believe is the most common presentation of MEN1. And then they have pancreatic neuroendocrine tumors like insulinomins that can cause weeple striate, which I mentioned, you know, the chronic episodes of hypo glycemia, right? But they can have pituitary problems, especially prolactinomins. So those prolactinomins again, going to show down your GNRH cause a hypo-gonadotropic hypo-gonadism. It's going to cause infertility, right? Or let's see, for example, they talk about infertility in a person that has a... In a person that has a nephoric syndrome that has led to chronic kidney disease. Well, think about it. If you have chronic kidney disease, what do you think is the organ that clears prolactin from your body? It's going to be your kidneys. Your kidneys are the primary organ that clears prolactin. So if your kidneys are not working, you're not going to be clearing prolactin very well. So you're going to have hyperprolactinemia. It's going to show down your HVG axis. You're going to get in trouble, right? So you see, they are just so many ways they can literally go after this prolactin business on your... on your exams. There are so many ways. Well, they can even give you like a chronic opioid user, right? And you notice that, man, this person is infertile. Opioids can cause infertility. Opioids can literally reach your prolactin levels and they can cause a... Again, a person to be infertile.

So there's something I want to keep on the back of your mind, right? Okay, what if they give you a question about a person that, you know, a person has like these causes on your fingers, a person has a BMI of like 17, it's like an athlete always working out, always exercising. And that's going to be a hypogonodotropic hypogonodotropic. It's a person who has an eating disorder, probably have an oral exam, or also something like that, right? Again, when you're not eating enough food, your body is not going to try to be supporting some other human beings. So you're going to show down your HPGX, is that constantly causes you to become a... to have a hypogonodotropic hypogonodotropic. Right? Remember, this will have a pretty high risk of osteoporosis, because then let me get this for a general, right? So the bone health is not... is not great. Something you can... I guess, side point, I'm throwing on, maybe, except. Okay, what if they give you a question about a person that has like... you know, has a very poor sense of smell, and gain for a tell. There's going to be common syndrome. Remember, in common syndrome, you have like a cell migration problem. So the cells that produce G&RH, they don't migrate properly, along with cells that, you know, kind of constitute Korean or one, they'll factor in nerve, right? So it's going to have an osmium and infertility.

Again, it's going to be a high pool, a good autotropic hypogonodotropic, because literally, they're not immunomica, G&RH, right? Or let's see, they give you a question about a person, like a woman, she's infertile, they tell you that a heart rate is 55, you know, that she always feels lethargic, she has put on quite a bit of weight, and you notice that her deep tender reflexes are decreased. It's going to be hypothyroidism. Hypothyroidism can cause infertility again. How does he do that? Well, the thing is, if you're hypothyroid, your T3 T4 is going to be low. So since your T3 T4 is low, your TRH is... there's not going to be negative feedback. Your thyroid tropy release in a hormone is going to shoot up. If your TRH shoots up, you're going to have a shoot up of your prolactin. TRH is a very powerful stimulator of prolactin secretion. If you make a ton of prolactin, you're going to shut down G&RH. You're going to get in trouble. Honestly, the big thing to know about infertility is that mechanism behind it. If you understand the mechanism behind it, many times you're going to be able to whistle through the questions that you see on you on your exception. Great. And you wonder, divine, what was this person's heart rate low? Well, think about it. When a person is hypothyroid, a person is hypothyroid, right, they have less T3. They're going to have less fewer beta-1 receptors on the acardiachmial site.

Because remember, one of the jobs of thyroid hormone is to make you put more beta-1 receptors in acardiachmial sites. If that's not happening well, you're going to be getting a lot of trouble, right? Because you're not going to have cataclyclic immediately this stimulation of those beta-1 receptors since you have fewer. So you're not going to have a proper T3 stimulation of your heart rate. Okay. Then what if they give you a question about a person that... You know, they tell you that this is some guy, and he has had like some kind of testicular trauma in the past. You know, maybe like a few months or a few years ago. And then now this man is unable to have any kids. And they tell you that man, this guy... Physical exam shows nothing. His hormone levels are completely normal. Blah, blah, blah, blah. If you see something like that, and want you to... This is almost like a diagnosis of exclusion. Want you to think of a guy that has like anti-sperm antibodies, anti-sperm antibodies. Many people don't realize this, but again, this is one of the reasons you learn this early in med school. But you know, there are many barriers in the body. There is the blood-brain barrier. A very critical barrier is the blood test, this barrier. And they wonder, why are we going to need a blood test, this barrier? Well, here's why. The thing is, think about all those spramaragonia and everything you learned about in med school. All these...

I almost feel like a lot of like genetic experimentation goes on in those things. Oh, let's do this. My toses here. My yoces here. My toses here. My yoces here. That can introduce all these strange things. You can make all these novel cells on the walknotch. You don't want all those things to get in contact with the body. You don't want to start making autoimmune things. So whenever you have something weird going on, like you have a breakdown of the blood test, because you've been in like testicular trauma, right? Or let's say you've had an infection in your testes that broke down the blood test, this barrier. That can then introduce your semen to the bloodstream. And then your body is going to start making antibodies against it. That's a very useful concept to know for you, exact. And you seem to know you, but I promise you, it is not. So if you have anti-spirumonti-buddies, then as this premise may just going to be destroyed, you're going to get in a lot of trouble. What if they give you a question about a lady that you've been infertile? And you're told that, man, this lady has... Whenever she has been in treating intercourse, it hurts her tongue. Whenever she tries to poop, it hurts her tongue. You know, they just have very painful men's ears. When you see something like this, I want you to think of endometriosis. Endometriosis is a very common cause of infertility on the eosimilis.

In fact, most times when the test endometriosis on the eosimilis, they're going to frame it as an infertility question. Remember, endometriosis, you're going to see infertility in the 3 Ds, right? This man or her, right? So the men's ears hurts. They're going to have dysparonia, a painful, painful, penetrated intercourse, and dyschysia. Whenever they poop, it hurts. Endometriosis can certainly be a cause of infertility. All I say, they give you a question about a person that has had many abortions, multiple DN Cs and whatnot, so multiple dilations and curatages. The person is infertile. Well, I want you to think of the person having an atomic-hole issue, like a structural issue of the uterus causing the problems. You'll be like, define what is that? Let me explain. Let me explain. If you keep having these DN Cs, DN Cs, DN Cs, unfortunately, one time you can scrape away the stem cells as opposed to the hormones, the stem cells of your uterus, as opposed to the hormones to make the uterine lining grow. If that happens, then you're going to be infertile. You're going to be infertile if you have that. You've destroyed the decedro, the cells that respond to hormones. That can certainly cause a lot of problems. Those people, they have the right hormones around. That's probably going to be a good example. Another good example of a normal bone at a trapecanal area. Remember what we talked about that with PCOS as well?

Although PCOS is a small fan, ovulatory issue, this is more fun, an atomic-hole issue with the uterus. Again, all these abortions, you keep scraping, scraping, scraping, scraping, the endometrial lining. Well, one day you can scrape the stem cells and then you have nothing to respond to. You have nothing to respond to hormones. Although I believe that is also treatable. Now, what if they give you a question about a guy, right? Tried with his wife many, many years, not fertile. And in detail, that on physical exam, you notice that he has like a bag of worms, a sensation in his testicle. That's going to be a varicoseal. Again, there's a reason why cryptorchidism is not good. Right? On descended testes. Now, I'll explain. This guy does not have cryptorchidism. He has a varicoseal, but I'm trying to tie two things together. So when you have cryptorchidism, you have an on descended testes. That's a problem. That's a huge problem. Well, why may that be a huge problem? Well, think about it. Is there reason why your testes are outside the body? Because he's kept at a temperature that's two degrees below cold-boiled temperature. That's the ideal temperature for sperm production. So if you have a varicoseal because your pump-iniform plexus has been all jumped up, by whatever situation that you have, then blood is like static in your pump-iniform plexus of veins that was not drained. Blood is static in your testicle. It kind of stays there. And this blood has high temperatures.

It's going to make that testicle hot. So it's going to keep your testicle at body temperature instead of two degrees below body temperature. Sperm is not going to be produced very well under those circumstances. And you're going to get in a lot of trouble. Right? So if you have a varicoseal, it can cause an infertility. Or let's say you give your question about infertility in a sex worker. You know, that's hot like a lot of infections and whatnot. You know, she has had a history of PID and many episodes of PID or whatever. Even one episode, as she's infertile. Then I want you to think about a person that has a scarring of the phallopian tubes. That's very high up to now. Right? So if you have pelvic inflammatory disease, or like a tumor variant abscess, all those infections and inflammation, right, can cause scarring of the phallopian tubes. If you scarring the phallopian tubes, that may mess up transport like movement of stuff. So like the Celia may not work. For those of you that have heard me see Celia, you probably can already begin to imagine something else I'm going to talk about with infertility pretty shortly here, but just I guess preview of clinical tractions. But these people, they've scarring the phallopian tubes. So they're going to have like poor motility of their eggs because those Celia, they can abate to move the eggs along.

If things can move along well, you know, you have scarring, just poor, poor environment in the phallopian tubes that can certainly cause infertility. That can absolutely positively cause infertility. Right? Well, let's see, they give you a question about a person that has recurrence, sign up, or an infection, sweat chloride is elevated. And this is a guy's infertile. That's cystic fibrosis. Right? Remember, these people have agenesis of the vast difference. The agenesis of the vast difference that can cause infertility. Or you can give you a female that, you know, has similar symptoms. Right? Well, you see that again, an increase in sweat chloride. Remember, females that have cystic fibrosis can also be infertile well because the circle micosis is too thick. We have very thick cervical mucus. It's going to make it very hard for sperm to penetrate. And that's going to cause you to be infertile. Right? Well, let's see, you see infertility in a woman that's under age 40. And she has a lot of menopostile symptoms, heart flashes, blah, blah, blah, blah. Now, once you think of premature ovarian failure, premature ovarian failure, that's a class equals going to present on exams. For whatever reasons, people's overresult failed. So they're not able to pull out eggs anymore. They're going to be infertile. Remember, typically on exams, we're going to diagnose that in women that are under age 40. Okay.

So for the person, people that are thinking about some silery association that I want to mention. Right? So what if they give you a question about a person infertile, chronic sign of pulmonary infections, the tell you that on chest radiography, you see bronchiectasis, the person has hearing loss. And they tell you that, man, that this person's point of maximal impulse. Right? You can populate more on the right side of the chest. Or you tell you that there's no problem on the left side of the chest. If you see this, this person has a primary silery dyskinesia. Guess what this person is specifically because these appear to have sites as inversors. That's going to be cartoonist syndrome. So you may wonder, divine. What's going on here? What's the deal with this point of maximal impulse? Well, the thing is, if you think about it, just literally take your hand as a listening to this podcast. Person on the left side of your chest, you know, like right under your nappolo, something like that. You're going to feel your heart beating. Right? That's your point of maximal impulse. That's like the live ventricular area. Your heart is beating pretty well. But when people have a primary silery dyskinesia, which is an autosomal recessive disease, by the way. So you can show up in both men and women on the exam. You're going to see these people. They're going to have issues wherever a silia is supposed to be. Let me explain. Right?

So remember, a silia, you know, they have all these dining arms. That's a very useful step one, step one tidbit. And I think it's actually those dining arms that have the mutation. They put a half primary silia, dyskinesia. Remember, we find silia like in the respiratory tract, both the operand or respiratory tract. We find them in the phallopian tubes. Let me be your hint. There, you find them in the phallopian tubes. Your sperm. Right? The sperm has phlegella. The phlegella contains silia. Right? In your middle ear, your station tube. All those places have silia. All those places have silia. Right? So if you have a problem with the silia, you're going to have a bunch of issues. Right? So one, you can have a respiratory infection because you're not able to clear respiratory pathogens well because the silia cannot beat a movie on eucosarone. Two, right? If your phallopian tube, if the silia is not working well there, they're not going to be able to move eggs along to get fertilized. Three, if you have primary silia, dyskinesia, your guy, your sperm does it work great. You have poor sperm motility. That can literally be an answering exempt. Instead of putting primary silia, dyskinesia has the cause of the problem that you can just put in paired sperm motility as an answer. Again, remember, the USM Ds these days, they don't come out with straight answers. They come out with derivative answers.

Like it's related to the right thing, but it's not exactly the thing that you know you've memorizing your on key deck. So you can make sure you have understanding of what's going on. Right? And they can have hearing loss. Right? Because think about it. Right? The middle ear, your station tube. Right? If you don't hear well, if your silia don't work right, I think even your hair cells contain silia. They don't work right, you're going to have hearing loss. Right? And this point of maximal impulse, again, you need this, this dining business, this silia business, to move stuff from the right side of the body to the stuff that's supposed to be on the left to move them to the left, you need this apparatus to work well. If it doesn't work well, then you have cytos and versors. That's why you're like, man, this person's point of maximal impulse is not possible. Or you can hear it only on the right side of the chest. Right? Or they can tell you that you don't hear any heart sounds on the left side of the chest. These are always, they can present this as a sort of, right? Think of people that have a primary silery, dyskinesia. Again, this stuff is pretty high yield to know for your exams. And again, I think with all these integrations we've done, honestly, if you understand this podcast, you should be pretty good with this stuff. So I'm going to end here. If you have any questions relating to any of the review courses I offer, they have to be starting next week Thursday.

For step one, just step three, have a test-taking course, a bio-stats class, that's four hours long. A social science is quality improvement, communications and ethics class, that's five hours long. And then I have a, for step two and three specifically, or shelf exams, I have a 20 hour course coming up the week after next week. And then I have a step one course coming up in early January and a 100 hour comprehensive review for step two and step three coming up in mail next year. So if you're interested in mail, these courses should be an email. Again, these courses are not lectures. There's going to be a lot of problem sets. We're going to use those problem sets to making just, again, like you see me make my podcasts. And there's going to be time. There's going to be a ton of time to take and answer people's questions. Again, these podcasts are on Apple Podcast, Google Podcasts and Spotify. Have a You Tube channel that you can check out, Divine Intervention, USM.ly Podcasts and videos. Have on the website called Divine Intervention Lifelessens.com. There's an Apple Podcast associated with that. Basically every week, I try to post about two podcasts. And from a political perspective, I address a life lesson. And many people have said, oh, Divine, I love your life lessons podcast. So I just made a separate website to handle those. Although I try to still toss in a few life lessons and life lessons at the end of these podcasts. So thank you for listening to me today.

Please, again, I beg you, listen to this podcast digest it. There's a ton of mechanisms in here. It's a short podcast with such super high-yield podcasts. So I'll see you in episode 494. Have a wonderful rest of your day. God bless you. Bye for now. Thank you.

Age.

Normal-gonadotropic hypogonadism.

Primary ciliary dyskinesia (PCD).

Nephrotic syndrome/Chronic Kidney Disease.

Anti-psychotics (e.g., risperidone, haloperidol).

Asherman's syndrome (scarring of the endometrial cavity).

Low T3/T4 $\rightarrow$ High TRH $\rightarrow$ High Prolactin $\rightarrow$ Suppression of GnRH, leading to hypogonadotropic hypogonadism.

Impaired renal clearance of prolactin.

Respiratory tract, fallopian tubes, sperm flagella.

Hypergonadotropic hypogonadism (due to primary ovarian failure/streak ovaries).

Endometriosis.

Pituitary prolactinomas $\rightarrow$ Hypogonadotropic hypogonadism.

Low T3/T4 $\rightarrow$ High TRH $\rightarrow$ High Prolactin $\rightarrow$ Suppression of GnRH, leading to hypogonadotropic hypogonadism.

Impaired renal clearance of prolactin.

Respiratory tract, fallopian tubes, sperm flagella.

Hypergonadotropic hypogonadism (due to primary ovarian failure/streak ovaries).

Endometriosis.

Pituitary prolactinomas $\rightarrow$ Hypogonadotropic hypogonadism.