12. Infertility Flashcards
1
Q
Describe epidemiology: Infertility (1)
A
10-15% of couples, must investigate both members of the couple
2
Q
Define: Infertility (1)
A
inability to conceive or carry to term a pregnancy after one year of regular, unprotected intercourse
3
Q
Define: Primary infertility (1)
A
infertility in the context of no prior pregnancies
4
Q
Define: Secondary infertility (2)
A
- infertility in the context of a prior conception
- Generally, 75% of couples achieve pregnancy within 6 mo, 85% within 1 yr, 90% within 2 yr
5
Q
When Should Investigations Begin for intertility? (5)
A
- <35 yr: after 1 yr of regular unprotected intercourse
- 35-40 yr: after >6 mo
- >40 yr: immediately
- Earlier if
- History of PID
- History of infertility in previous relationship
- Prior pelvic surgery
- Chemotherapy/radiation in either partner
- Recurrent pregnancy loss
- Moderate-severe endometriosis
6
Q
Name: Ethical Considerations in Infertility Treatment (3)
A
- Infertility demands non-judgmental discussion
- Ethical issues surrounding therapeutic donor insemination in same sex couples, surrogacy, donor gametes, and other advanced reproductive technologies are still evolving and remain controversial
- If the doctor finds that certain treatment options lie outside of their moral boundaries, the infertile couple should be referred to another physician
7
Q
Name FEMALE etiologies: Infertility (5)
A
- ovulatory dysfunction (15-20%)
- outflow tract abnormality (15-20%)
- endometriosis (15-30%)
- multiple factors (30%)
- unknown factors (10-15%)
8
Q
Name ovulatory dysfunction etiologies for interfility (5)
A
- hypothalamic (hypothalamic amenorrhea)
- stress, poor nutrition, excessive exercise (even with presence of menstruation), history of eating disorders
- pituitary (prolactinoma, hypopituitarism)
- ovarian
- PCOS
- primary ovarian insufficiency
- luteal phase defect (poor follicle production, premature corpus luteum failure, failed uterine lining response to progesterone), poorly understood
- systemic diseases (thyroid, Cushing’s syndrome, renal/hepatic failure), diabetes
- congenital (Turner’s syndrome, gonadal dysgenesis, or gonadotropin deficiency)
9
Q
Name outflow tract abnormality etiologies for interfility (3)
A
- tubal factors (20-30%)
- PID
- adhesions (previous surgery, peritonitis, endometriosis)
- ligation/occlusion (e.g. previous ectopic pregnancy)
- uterine factors (<5%)
- congenital anomalies, bicornuate uterus, septate uterus, prenatal DES exposure, intrauterine adhesions (e.g. Asherman’s syndrome), fibroids/polyps (particularly intrauterine)
- infection (endometritis, pelvic tuberculosis)
- endometrial ablation
- cervical factors (5%)
- hostile or acidic cervical mucus, anti-sperm antibodies
- structural defects (cone biopsies, laser or cryotherapy)
10
Q
Describe investigations: Infertility (4)
A
- ovulatory
- day 3: FSH, LH, TSH, prolactin ± DHEA, free testosterone (if hirsute) add estradiol for proper FSH interpretation
- day 21-23: serum progesterone to confirm ovulation
- initiate basal body temperature monitoring (biphasic pattern)
- postcoital test: evaluate mucus for clarity, pH, spinnbarkeit/fibrosity (rarely done)
- tubal factors
- HSG (can be therapeutic – opens fallopian tube)
- SHG (can be therapeutic; likely less – opens fallopian tube)
- laparoscopy with dye insuffiation (or tubal dye test) rarely done as diagnostic
- peritoneal/uterine factors
- HSG/SHG, hysteroscopy
- other
- karyotype
11
Q
Describe FEMALE treatment: Infertility (3)
A
- education: timing intercourse relative to ovulation (from 2 d prior to 2 d following presumed ovulation), every other day
- medical
- ovulation induction
- may add
- surgical/procedural
12
Q
Describe: Ovulation induction (3)
A
- clomiphene citrate (Clomid®): estrogen antagonist causing a perceived decreased estrogen state, resulting in increased pituitary gonadotropins; which increases FSH and LH and induces ovulation (better results if anovulatory)
- followed by β-hCG for stimulation of ovum release
- Letrozole: aromatase inhibitor. May be associated with a higher rate of live births in patients with PCOS
13
Q
What can you add additionally for ovulation induction? (6)
A
- bromocriptine (dopamine agonist) if elevated prolactin
- dexamethasone for hyperandrogenism (adult onset congenital adrenal hyperplasia)
- metformin (for PCOS)
- luteal phase progesterone supplementation for luteal phase defect (mechanism not completely understood)
- anticoagulation and ASA (81 mg PO OD) for women with a history of recurrent spontaneous abortions (for antiphospholipid antibody syndrome)
- thyroid replacement to keep TSH <2.5
14
Q
Name surgical/procedural interventions for infertility (13)
A
- tubuloplasty
- lysis of adhesions
- artificial insemination: intracervical insemination (ICI), intrauterine insemination (IUI), intrauterine tuboperitoneal insemination (IUTPI), intratubal insemination (ITI)
- sperm washing
- IVF ( fertilization)
- IFT (intrafallopian transfer)
- GIFT* (gamete intrafallopian transfer): immediate transfer with sperm after oocyte retrieval
- ZIFT* (zygote intrafallopian transfer): transfer after 24 h culture of oocyte and sperm
- TET* (tubal embryo transfer): transfer after >24 h culture
- ICSI (intracytoplasmic sperm injection)
- IVM (in vitro maturation)
- ± oocyte or sperm donors
- ± pre-genetic screening for single gene defects in karyotype of zygote
*not performed in Canada
15
Q
Name MALE etiologies for infertility (5)
A
- varicocele (>40%)
- idiopathic (>20%)
- obstruction (~15%)
- cryptorchidism (~8%)
- immunologic (~3%)
