14. Female infertility Flashcards
Define: Infertility (1)
Inabilityto conceive after 1 yr of regular intercourse without contraception
Define: Fecundability (1)
Probability that a single cycle will result in pregnancy (20%–25%)
Define: Fecundity (1)
Probability that a single cycle will result in a ive irth
In women, there is a significant age-related ↓ fertility and ↑ in spontaneous miscarriage largely attributable to what? (2)
- progressive follicular depletion
- ↑ incidence of abnormalities of aging oocytes.
Infertility affects approximately __% of couples.
15%
Female-associated factors account for approximately __% of infertility problems.
50%
Male-associated factors contribute significantly to infertility in up to approximately __% of couples.
35%
Approximately __% of couples will have “unexplained infertility” (cause is uncertain).
10% to 15%
Describe phases and lengths of phases in Menstrual Cycle (4)
- Menstrual phase: 1 to 4 d
- Follicular phase: 5 to 13 d
- Ovulation: 14 d
- Luteal phase: 15 to 28 d
Name mechanisms of female infertility (3)
- Ovulatory dysfunction (20%–40%)
- Anatomic abnormality (25%–35%)
- Other (40% –45%)
Name DDX: Ovulatory dysfunction causes of infertility (6)
- Hypothalamic (hypothalamic disorder 2° to stress, poor diet, or excessive exercise)
- Pituitary (prolactinoma, medication-induced, hypopituitarism)
- Polycystic ovary syndrome (PCOS)
- Primary Ovarian Insufficiency
- Systemic disease (thyroid dysfunction)
- Anovulation associated with transition to menopause
Name DDX Anatomic abnormality causes of infertility: Uterine factors (4)
- Infection (chronic endometritis)
- Fibroids
- Congenital anomalies (agenesis, uterine septum, bicornuate uterus)
- Asherman syndrome
Name DDX Anatomic abnormality causes of infertility: Cervical factors (3)
- Acidic cervical mucus
- Antisperm antibodies
- Structural defects (previous LEEP, cone biopsy, cryo/laser Rx)
Name DDX Anatomic abnormality causes of infertility: Tubal factors (3)
- PID
- Tubal occlusion (previous ectopic)
- Tubal adhesions (previous surgery, endometriosis)
Name DDX other causes of infertility (3)
- Endometriosis
- Multifactorial
- Unexplained
Name Lifestyle factors Associated with infertility (5)
- Obesity
- Smoking
- EtOHuse
- Drug use
- Caffeine
Name Risk factors of infertility (6)
- Hx of PID
- Hx of tubal or pelvic surgery
- Hx of endometriosis
- Prev. EP
- Inutero DES exposure
- Hx of septic abortion
Describe approach of infertility (4)
- Evaluate for male infertility factor
- Determine whether patient cycles are ovulatory
- Identify factors that ↑ risk of tubal infertility
- Examine patient for signs and Sx of endocrinopathy and gynecologic disease
Describe Evaluation of Coital Practices (4)
- Sexual dysfunction (dyspareunia, impotence,etc.)
- Frequency of intercourse
- Timing of intercourse
- Use of lubricants
Describe: Physician’s Approach to Infertility (4)
- Discuss in a non judgmental manner
- Full disclosure to patients (make certain patients have full access to relevant information)
- Identify if certain options lie outside your moral boundaries and refer to another MD if appropriate
- Protect the patients’ right to freedom of moral choice
One year of infertility is not a prerequisite for who? (3)
- All women > 35yr
- Women with irregular or infrequent menses
- Women with a Hx of PID or endometriosis
Describe HX evaluation: Infertility (10)
- Developmental Hx
- Coital practices
- Previous STI
- Previous infertility
- Obstetric Hx
- Past surgical Hx
- FHx infertility
- Medications
- Substance abuse
- ROS (Sx of hyper PRL, FSH, etc.)
Describe HX evaluation: Physical exam (8)
- Breast (Tanner staging, discharge)
- Sx of hyperandrogenism
- Speculum and bimanual exam
- Cervial discharge
- Uterus/adnexa
- Tenderness
- Shape
- Mobility
How to R/O ovulatory dysfunction? (6)
- Basal body temperature graph
- Urinary LH
- D3 FSH, LH
- D 21-23 serum progesterone
- Serum TSH, PRL, 17-OHP
- Transvaginal U/S
How to R/O structural abnormality? (5)
- Saline infusion sonography
- Hysterosalpingogram
- Hysteroscopy
- Laparoscopy
- *R/O infection: swab for STI, mycoplasma, ureoplasma
Describe: Ovarian reserve (1)
the size and quality of the remaining ovarian follicular pool intended to predict future fecundability or provide prognostic information regarding likelihood of successful Rx.
How to Consider assessment of ovarian reserve in case of infertility? (4)
- D 3 FSH, estradiol
- Clomiphene citrate challenge test
- Antral follicle count (via transvaginal U/S ) (a bnorma l <10)
- Anti-mullerian hormone (AMH)
How to R/O male factor in infertility? (2)
- Semen analysis
- Physical exam
Describe the approach to infertility (Figure)
Name: Indications for Specialty Referral in Couples Presenting with Female Infertility (7)
Factor infertility (gynecologist and/or reproductive endocrinology and infertility specialist):
- Female with abnormal day 3 FSH and/or estradiol
- Female with abnormal hysterosalpingogram (HSG) due to:
- Tubal abnormalities
- Abnormal intrauterine cavity
- Women with laparoscopy showing severe pelvic adhesions
- Women in whom pregnancy fails to occur after surgical Rx of endometriosis
- Couples desiring IVF and/or other advanced reproductive technologies
Describe Management of female factor infertility (7)
Describe Counsel and education in infertility (5)
- Time intercourse in relation to ovulation (2d before to 2d after)
- Pre-conceptual use of folic acid (0.4–1.0 mg/d at least 3 mo before conception)
- Options of: (a) pursue Rx, (b) live child free, or (c) adoption
- Setting appropriate expectations of Rx (goals, limitations, success rates)
- Referral to psychologists, support groups etc. as required
Describe the management of infertility if: Infection (1)
Antibiotics (see STI topic)
Describe the management of infertility if: Ovulatory dysfunction (4)
