204. Female Infertility

Question 1

Definition of Infertility (Primary, Secondary, when to evaluate), cycle fecundability, cycle fecundity

When does fertility peak?
Why does fertility decline with age?

Answer 1

Infertility: ONE YEAR of unprotected intercourse without conception
Primary: No prior conceptions
Secondary: at least 1 prior conception
Evaluate women >35yo after 6mo attempting conception

Cycle fecundability: likelihood single menstrual cycle results in pregnancy
Cycle fecundity: likelihood single menstrual cycle results in live birth

Aging: older age = decreasing egg quality = higher risk of aneuploidy and miscarriage

Peak fertility age 20-24, starts declining progressively after 30-32

Question 2

What are the 4 broad categories for infertility ddx?

Answer 2

1. Anatomic Disorders (40% women infertility)
2. Ovulatory Dysfx (40% women infertility)
3. Oocyte Factors/Decreased Ovarian Reserve
4. Male Factors (35% of M + W infertility)

Question 3

What are causes of women infertility in regard to anatomic disorders (5) and ovulatory dysfx (5). Define decreased ovarian reserve

Answer 3

Anatomic: Congenital: mullerian duct abnormalities
acquired: fibroids, polyps, Asherman’s syndrome (iatrogenic intrauterine adhesions and scarring), Fallopian Tube Abnormalities (ascending infection/pelvic surgery)

Ovulatory Dysfx

1. PCOS: most common female endocrinopathy, oligo-amenorrhea, hyperandrogenemia, US: polycystic ovaries, assoc with ins resistance + obesity
2. Hypothalamic Amenorrhea: usually functional (excessive exercise, inadaquate nutrition, stress) due to disruption of pulsatile GnRH secretion
3. HyperPRL
4. Thyroid Disease (hypothyroid alters cycle more)
5. Primary Ovarian Insufficiency (low egg supply)

Decreased ovarian reserve: lose eggs more quickly/sooner than expected (normal age of menopause - 51 no eggs left)

Question 4

What is the effect of maternal age on uterus?

What is “Unexplained Infertility”

Answer 4

Maternal age has NO effect on uterus, endometrium fx (donor egg IVF birth rates do not vary with age)

Unexplained infertility: Dx of EXCLUSION - pt has bilateral tube patency, normal uterine cavity, ovulatory fx, good semen quality
Theory: poor oocyte quality (cannot be found with current tests - abnormal sperm fx, fertilization, implantation, embryo development)

Question 5

Assessing Infertility
How can you assess uterine cavity?
Assess Tubal Patency?
Assess Ovulation?
Assess Male Factor?

Answer 5

Uterine Cavity: Hysteroscopy, Transvaginal US (can’t see inside uterine cavity - closed/non-distended), HSG (insert fluid into uterus and image under fluoroscopy), Sonohysterogram (SIS): saline US fully investigate uterus FIRST LINE

Tube Patency: HSG (hysterosalpinogram - image tracer filling uterus and tubes; preferred method for tubal infertility), SIS (simple safe cheap), GOLD STD: laparascopy with chromopertubation (operation)

Ovulation: consistent hx (regular cycles, moliminal sx before menses), basal body temp charting, serum P on day 21 of 28 (1 week after ovulation), home ovulation predictor kits
- Ovulation reserve: Day 3 FSH (baseline level): normal <10, FSH > 10-15 abnormal (brain working hard to command ovary, low follicles left)
AMH: from GCs, correlates with # small antral follicles, levels decline as mp approaches
AFC: antral follicle count: transvaginal US measurement of follicles 2-10mm in size in both ovaries

Male factor: sex fx, hx, fam hx, semen analysis (volume >1.5mL, sperm conc >15million/mL, >40% motile, >4% normal shape morphology), low threshold for urologic referral

Question 6

Infertility Tx

• Anatomy Problems
• Ovulatory Dysfx
• Decreased Ovarian Reserve
• Male Factor Tx
• Unexplained Infertility Tx

Answer 6

Anatomy: Surgery, IVF, Gestational Carrier

Ovulatory Dysfx: Tx underlying endocrinopy
Induce ovulation: Clomiphene Citrate (SERM to induce ovulation), Letrozole (oral aromatase inhibitor, less E to make more negative fb = more FSH, 1st line for PCOS), Injectable Gonadotropins (purified urinary FSH, LH, recombinant FSH, LH, hCG, VERY COSTLY, risk of multiple pregnancy, ovarian hyperstimulation syndrome (ovaries make too many eggs, intravascular depletion)

No tx for decreased ovarian reserve - consider oocyte donation

Male factor tx: intrauterine insemination (IUI) for modest abnormalities; IVF with ICSI (intracytoplasmic sperm injection - put sperm in ovum); Donor insemination

Unexplained: 2-4% have cycle fecundability w/o tx
Clomiphene + IUI improve cycle fecundability slightly, best improvement is IVF (higher success rate but more costly and risky)