2- Infertility and Abortions Flashcards
What is defined as the probability of achieving a pregnancy in one menstrual cycle?
Fecundability
What is defined as infertility in pts 35 yrs and younger?
Inability to conceive after 12 months of unprotected intercourse
What is defined as infertility in pts 35 yrs and older?
Inability to conceive after 6 months of unprotected intercourse
What is the difference between primary and secondary infertility?
Primary- infertility in pts who have never conceived (increases with age)
Secondary- infertility in pts after prior fertility
What is the greatest contributor to infertility as a couple?
Female factor infertility > male factor infertility
What are the 4 main categories of male factor infertility?
Endocrine/ systemic disorders
Primary testicular defects in spermatogenesis
Sperm transport disorders
Idiopathic male infertility
In regards to semen analysis, what must be done prior to providing the sample and how many samples are taken?
2-7 days of sexual abstinence
2 samples, 1-2 weeks apart
What factors are evaluated as part of semen analysis? (according to WHO criteria) (7)
Volume
Sperm concentration
Total sperm #
Morphology
Vitality
Progressive motility
Total motility (progressive + nonprogressive)
What is the most common congenital abn causing hypogonadism and can be a cause of infertility in men?
Klinefelter’s syndrome (47 XXY)
What are the main contributing factors to female infertility?
Ova, patent oviduct, anatomic abns of uterus
What are the main complications of ovulation a/w infertility in females?
PCOS, thyroid dysfunction, hyperprolactinemia
Lack of progesterone in PCOS has what effect on menstruation?
Results in unopposed estrogen = hyperplastic growth of endometrial lining = irregular sloughing = oligomenorrhea
How does thyroid dysfunction contribute to infertility?
Can lead to oligomenorrhea or amenorrhea
What factors/ circumstances lead to high prolactin?
Breastfeeding
Breast stimulation/ intercourse
Extreme exercise
Meds (Risperidone)
If serum prolactin levels are elevated, repeat test should be performed with instruction of what?
No exercise, intercouse, breast stimulation + fasting
(24 hours)
If prolactin levels are persistently elevated, what should be evaluated for?
Pituitary adenoma with MRI
What is the tx of anovulation due to PCOS?
Weight loss
Provera cycling
Metformin
Clomiphene
What is the tx of anovulation due to hyper or hypothyroidism?
Hyper = PTU
Hypo = Levothyroxine
What is the tx of anovulation due to hyperprolactinemia?
Bromocriptine, but d/c once (+) pregnancy test
What drugs are used for ovulation induction?
Letrozole- 1st line (but not FDA approved for this use- pt edu)
Clomiphine
(often used w/ intrauterine insemination (IUI))
What is the short term, but potentially life threatening SE a/w use of Clomiphine and Letrozole for ovulation induction?
Ovarian hyperstimulation (can lead to thromboembolic event)
What often results from untreated STDs/ PID and can lead to infertility?
Occluded oviduct
Hydrosalpinx, mucous, and anatomic anomalies can lead to what complication, thus leading to infertility?
Occluded oviduct
In addition to occluded oviducts, what other tubal factors can lead to infertility?
Injury/ surgery to oviduct
(ex. salpingectomy, previous ectopic pregnancy)
How can tubal factors be ruled out as the cause of infertility?
Hysterosalpingogram (HSG)
(dye fills uterine cavity, shows possible occlusion)
What are the limitations to HSG?
Evaluates for tubal patency, not function
(also not covered by most insurances +/- painful)
What is the treatment for tubal factors as a cause of infertility?
IVF = 1st line
Surgical tubal repair (increased risk of ectopic pregnancies)
What are the 2 most important questions to ask at an infertility visit?
Regular menstrual cycles, frequency of intercourse
Mittelschmerz (pain w/ ovulation) and cervical mucous described as “spinnbarkeit” or “egg white” are signs of what?
Regular ovulation
Medical hx of what could indicate male infertility?
Hx of mumps
What surgical hx has the potential to lead to male infertility?
Vasectomy, hernia repair, orchiectomy
In addition to medical hx, meds, and social hx, what other hx should be obtained for eval of possible male infertility?
Surgical hx
Developmental hx (loss of body hair/ decreased shaving, pubertal developmental milestones, learning disabilities)
What “combined M/F” questions should be asked at an infertility visit?
Primary vs secondary infertility (including hx of miscarriages/ abortions)
Time period trying to conceive
Previous use of contraceptive
What are important PE findings for female infertility visit?
BMI (> 27 or < 17)
Pain w/ pelvic exam (esp posterior cul de sac)
Is it necessary to wait 6-12 months for possible conception if known specific infertility cause with either partner?
No- refer early
When might an elective abortion be performed?
Unplanned pregnancy, fetal anomalies, maternal health
What meds are used for elective abortion and when can they be used?
Misoprostol, Mifepristone
Up to 70 days of gestational age
The following are all options for what?
Suction D+C, dilation and evacuation, stimulation of labor
Surgical options for elective abortion
(decision based on gestational age)
What condition is considered a spontaneous abortion (SAB)?
Miscarriage- pregnancy loss prior to 20 weeks gestation
Most common complication of pregnancy
What is included in the workup for spontaneous abortion?
CBC, Rh type, HCG quantitative, pelvic/ transvaginal US
What is the most common cause of spontaneous abortion?
Abnormal karyotype (usually occurs in 1st trimester)
What is required for Rh negative women with spontaneous abortion?
Rhogam injection
Are genetic studies performed for isolated SAB?
Rarely
What type of SAB is a/w a closed cervical os and presents with bleeding and (+) urine pregnancy test?
Threatened
What type of SAB is a/w an open cervical os and presents with bleeding?
Inevitable
What type of SAB is a/w a closed cervix, absent fetal heartbeat and NO bleeding?
Missed
How is recurrent abortion (aka “habitual aborter”) defined?
3+ consecutive losses prior to 20 weeks
(risk of future SABs increase with each subsequent SAB)
What is the more common congenital uterine anomaly?
Bicornuate (partial)
What are the the causes of recurrent abortion? (5)
Abn karyotype
Uterine malformations
Antiphospholipid antibody
Chronic uncontrolled medical conditions
Insufficient progesterone levels
What is included in the workup for recurrent abortion with respect to general hx?
Maternal age, hx of chronic diseases
What karyotype information should be obtained in workup for recurrent abortion?
Karyotype of both parents + aborted embryo
Aside from general hx and karyotype information, what else is included as part of the workup for recurrent abortion? (4)
Luteal phase progesterone
Antiphospholipid antibody
Lupus workup
Uterine cavity eval
