28 Infertility Lieu Flashcards
What is Fecundability?
Monthly probability of conception. Approximately 20-25% in normal couples actively attempting to achieve pregnancy
What is Primary Infertility?
Lack of conception after one year of regular unprotected sexual intercourse
What is Secondary Infertility?
Conception occurred previously, even if pregnancy was not successful (previous children, ectopic pregnancies, abortions)
What is recurrent pregnancy loss?
Two or more failed pregnancies
What is Subfertility?
Most eventually able to conceive
Usually evaluations for infertility are done after one year of not conceiving, when does the American Society for Reproductive Medicine (ASRM) recommend evaluation and treatment before 12 months?
Female > 35 years (after 6 months). History of oligoamenorrhea or amenorrhea. Known or suspected uterine or tubal disease or endometriosis. Male known to be subfertile
What is Endometriosis?
Endometrial implants outside of the uterus. Each month, endometrial implants break down and bleed but have no way of being expelled from the body
What history in females can lead to infertility?
Aging (decreases number/quality of eggs). Onset of menses. Length/frequency of cycle. Contraception. Coital history. Previous pregnancies or abortions. Pelvic surgery, PID, endometriosis, STDs. Systemic illnesses
What history in males can lead to infertility?
Pubertal development. Systemic illness. Previous surgery or injury. Medications. Drug/alcohol use. Prior conceptions achieved
When should a Semen Analysis (SA) be obtained?
Abstain from ejaculation 3-7 days before. SA looks at volume, count, motility, morphology
What is ovulation prediction?
Most fertile time: from 2 days (up to 5 days) before ovulation to 24 hours (or so) after ovulation
What does a Hysterosalpingogram (HSG) look at?
Uterine capacity. Tubal patency
How does basal body temperature charting work?
Take first measurement on first day of menstrual period. Take temp for at least 5 minutes, each AM upon awakening, before any activity or getting out of bed. Measure to nearest 0.1 degree. Chart temperatures daily. Temp: lower before vs. after ovulation (biphasic)
What is the Nadir on temperature charting?
At least 0.1 degree lower than previous six days. Signals approach of ovulation; rise of 0.4-0.6 degrees between 2 consecutive days indicates that ovulation has occurred
What are the potential problems with basal body temperature charting?
Accuracy of reading. Cycle variability. Illness, febrile episodes. Medications. Alterations in sleeping pattern. Daily lifestyle fluctuation. Missing measurements
When should ovulation tests be done?
Begin testing 3-4 days before expected day of ovulation (around day 10). Test uterine daily at same time of day until color change is seen. Stop testing for cycle after (+) color change. Predict ovulation 24-40 hours after distinct color change. Timing crucial - may require stopwatch or watch w/ second hand for testing procedures
What does an Ovulation Microscope do?
Detect hormone changes that occur prior to and during ovulation. Test first thing in the morning; never after eating, drinking, or brushing teeth at least 2-3 hours before taking test. Look for “ferning” or crystal patterns produced by increase in estrogen that takes place prior to ovulation. With positive “ferning” pattern, ovulation likely to occur within 24-72 hours
How does the OV-Watch Fertility Predictor work?
Worn on wrist while sleeping. Measures changes in chloride ion levels secreted in perspiration every 30 minutes. Identifies 4-5 day fertility window when pregnancy is possible. Detects chloride surge 3 days prior to estrogen surge, 4 days prior to LH surge, 5 days prior to ovulation
How does SpermCheck Fertility work?
Positive result: sperm count above 20 million sperm per mL of semen (“normal” sperm count). Negative result: sperm count below 20 million sperm per mL
How can Omega-3 FA: DHA, at least 200 mg/day help pregnant women?
Baby: improve brain function, eye function. Mother: decrease risk of preterm delivery, post-partum depression
What OTC medication should be avoided especially before/around ovulation?
NSAIDs, COX-2 inhibitors. Impair fertilization, embryo development, implantation, continuing pregnancy
Why does the male need to have a healthy BMI as well to help with fertility?
Overweight men have lower testosterone levels and abnormal semen analysis
What are some factors that impair spermatogenesis?
Alcohol. Caffeine. Cell phone radiation. Thermal exposure (i.e. hot tubs). Anabolic/Androgenic steroids
How can antioxidants help with fertility for men?
Men who presented with high levels of DNA damage or oxidative stress may factor in early recurrent embryo loss. Recommend: increase intake of antioxidant-rich foods (vit C, vit E, B-carotenes, zinc) for at least three months
What is ProXeed Plus?
Special blend to optimize sperm health, reduce oxidative damage, support formation and maturation of sperm. Initial results may be seen in as few as 3 months; take for at least 6 months for optimal results. Take as long as attempting to conceive
What do you want to minimize with infertility treatment?
Risks: ovarian hyperstimulation, multiple gestation. Physical discomfort. Psychological stress. Financial costs
What is the treatment of infertility dependent on?
Female age. Male partner status. Ovarian status. Tubal status. Uterine status. Peritoneal status
What are the different treatment strategies for infertility?
Expectant management. Surgical. Medical. Controlled ovarian hyperstimulation (COH) w/ timed intrauterine insemination (IUI). Assisted reproductive technology (ART) procedures
What is used for ovulation induction?
Clomiphene Citrate and/or Gonadotropins
What is Clomiphene Citrate (Clomid, Serophene)?
Nonsteroidal ovulatory stimulant - weakly estrogenic and also anti-estrogenic properties. Treatment of ovulatory dysfunction in women desiring pregnancy. Use: Ovulation induction, luteal phase support, unexplained infertility
How is Clomiphene Citrate (Clomid, Serophene) dosed?
50mg oral tablets: initiate with 50mg/day x 5 days. Begin on 2nd-5th day of cycle. Increase in 50mg increments each cycle until ovulation achieved (may require 12.5-25 mg/day, up to 100mg/day). Ovulation usually 5-10 days after last tablet
What are the ADRs/complications with Clomiphene Citrate (Clomid, Serophene) use?
Vasomotor symptoms (hot flushes, sweats). Emotional lability (mood swings, depression). Pelvic discomforts. Nausea, vomiting. Breast tenderness. HA. Visual symptoms. Cervical mucus abnormalities. Ovarian hyperstimulation. Multiple gestation (increased risk)
What are 1st generation Gonadotropins?
Human menopausal gonadotropins (hMG, menotropins); FSH and LH: Repronex (SC or IM)
What are 2nd generation Gonadotropins?
Purified human menopausal gonadotropins (hMG, menotropins); FSH and LH: Menopur (SC)
How is hMG/FSH dosed?
Initiate 75-150 IU/d x 7-14 days. Begin on 3rd-5th day of cycle. May require up to 450 IU/day. hCG required for ovulation, oocyte maturation
What are the side effects/complications of hMG/FSH use?
“Flu-like symptoms”: fever, chills, HA, musculoskeletal aches, joint pains, malaise. GI symptoms. Pain, rash, swelling at injection site. Body rashes, dizziness. Multiple gestation (increased risk). Ovarian hyperstimulation syndrome
What is Ovarian Hyperstimulation Syndrome (OHSS)?
May progress rapidly to become a serious medical event (life threatening). Apparent dramatic increase in vascular permeability: can result in rapid accumulation of fluid in peritoneal cavity, thorax, and potentially pericardium. Follow patients for at least 2 weeks after hCG administration. Usually resolved spontaneously with onset of menses
What are some early warning signs of OHSS?
Severe pelvic pain, nausea, vomiting, sudden weight gain, reduced urine ouput. More common, more severe, more protracted if pregnancy occurs
What are the Human Chorionic Gonadotropin (hCG) drugs used?
hCG: Novarel (IM), Pregnyl (IM). Choriogonadotropin alfa (r-hCG): Ovidrel (SC)
What does hCG do?
Stimulates endogenous LH surge before ovulation. Final oocyte maturation and ovulation induction. Also used to provide luteal-phase support (stimulates corpus luteum to produce progesterone)
What are the ADRs associated with hCG?
Nausea. Edema. Gynecomastia. Pain at injection site. HA. Irritability. Restlessness. Depression. Fatigue
What are the ADRs assocaited with r-hCG?
Abdominal pain, injection site reactions, nausea, vomiting
What is Assisted Reproductive Technology (ART) Procedures?
Meds used to stimulate egg production (ovulation induction) or ovaries monitored (natural cycle) with intent of having embryos transferred. Used in IVF and other procedures
What is ZIFT?
Zygote Intrafallopian Transfer
What is Intracytoplasmic Sperm Injection (ICSI)?
Single sperm directly injected into the egg. Male factor infertility
What is Preimplantation Genetic Diagnosis (PGD) used for?
Embryo analysis for inheritable genetic disease, advanced maternal age, unexplained recurrent pregnancy loss
What are the primary uses of GnRH agonists and antagonists?
Inhibit premature LH surges in women undergoing COH; decrease cycle cancellation
What do GnRH Agonists do?
Leuprolide Acetate (Lupron (SC)). Pituitary down-regulation. Not FDA approved for infertility
What do GnRH Antagonists do?
Ganirelix Acetate (SC), multiple dose. Cetrorelix (SC), multiple or single dose. Pituitary suppression
What is the GnRH Agonist “Long Protocol”?
Day 21 (Lupron 1mg). Day 2 or 3 (Lupron 0.5mg + FSH or hMG). Then hCG, OR, ET
What are the GnRH agonist side effects/complications?
Vasomotor symptoms (hot flushes, sweats). Emotional lability. Vaginal dryness. Memory disturbances. HA. Insomnia. Joint and muscle stiffness. Pain at injection site. Panic attacks
What is the use of Progesterone?
Used to induce withdrawal-bleeding. Used for luteal-phase support (postovulatory endometrial support). Used for luteal support with ARTs. Used with estrogen for hormone replacement therapy (HRT) for recipients of oocyte donation (OT) or frozen-thawed embryo transfer (ET). Begin after ovulation. Continue until menses occurs, or (-) pregnancy test. (+) pregnancy: continue to approximately 10-12 weeks gestation
What are the side effects/complications of Progesterone use?
Breast enlargement. Nausea. Constipation. Drowsiness. Somnolence. Dizziness. Fatigue. HA. Cramps. Bloating. Increase in appetite. GE reflux (heartburn, cough). Mental depression. Fluid retention. Emotional lability. PMS-like symptoms
What are the ADRs assocaited with Endometrin (vaginal Progesterone insert)?
Most common: post-oocyte retrieval pain, abdominal pain, nausea, ovarian hyperstimulation syndrome
What are the contraindications for Endometrin (vaginal Progesterone insert) use?
Known missed abortion or ectopic pregnancy. Liver disease. Known or suspected breast CA. Active arterial or venous thromboembolism or severe thrombophlebitis, or a history of these events
Why is Estrogen sometimes used in infertility?
Stimulates proliferation of endometrial lining for embryo implantation. Thins cervical mucus during peri-ovulatory period. Used with progesterone for hormone replacement therapy (HRT) for recipients of oocyte donation or frozen-thawed embryo transfer. Not FDA approved for infertility. Estradiol (micronized): Estrace, oral. Estradiol transdermal system: Estraderm
What are the ADRs/complications of Estrogen?
N/V/D. Abdominal cramps. Bloating. Mental depression. Dizziness. HA. Breast tenderness or enlargement. Fluid retention. Thromboembolic disorders
Why are Oral Contraceptives sometimes used for infertility?
Before initiation of ovulation induction. Induce hypogonadotropic state. Synchronize follicular development. Improve ovarian response to COH. Suppress CL function - prevent LH rise. Schedule beginning of med cycle or retrieval. Once protocol: Initiate hMG/FSH 3-7 days after d/c OCs. Not FDA approved
What is Polycystic Ovary Syndrome (PCOS)?
Enlarged ovaries containing numerous small cysts (polycystic). Infrequent, absent, and/or irregular menstrual periods. Excess androgen: Hirsutism (excessive hair growth on face, chest, stomach, back, thumb, or toes. Acne, oily skin, or dandruff. Androgenic alopecia: male-pattern baldness or thinning hair. Weight gain, obesity, difficulty becoming pregnant).
What do people with PCOS have higher rates of?
Miscarriage. GDM. Preeclampsia (pregnancy-induced high blood pressure). Premature delivery
What are the hormones like in PCOS?
Increase LH. Increase ratio of LH to FSH. Overproduction of androgen by ovaries. Insulin resistance, hyperinsulinemia. Impaired glucose tolerance –> T2DM. CVD. Inflammation (elevated C-reactive protein). Nonalcoholic steatohepatitis. Sleep apnea. Anxiety and depression. Abnormal uterine bleeding. Endometrial carcinoma
How does Metformin help predominantly obese PCOS patients?
Improves restoration of regular menses and ovulation; no data supporting improved pregnancy rate. CC-resistant PCOS: addition of Metformin to CC improved ovulation and pregnancy rate
What do Aromatase Inhibitors do?
Interferes with last enzymatic step of estrogen synthesis (conversion of androgens into estrogen). Reduction of estrogen production –> interferes with negative feedback exerted by ovary –> elevates gonadotropins –> stimulates premenopausal ovarian function. Can be used for stimulating follicle maturation and inducing ovulation. Not FDA approved for infertility
What are the Aromatase Inhibitors used?
Letrozole (Femara), Anastrozole (Arimidex)
What are the advantages of Aromatase inhibitors over CC?
No undesirable anti-estrogenic effects on cervical mucus and endometrium
How many embryos (2-3 days after cell fertilization) can be transferred in females < 35 in the absence of extraordinary circumstances?
No more than 2 embryos
How many embryos (2-3 days after cell fertilization) can be transferred in females 35-37 in the absence of extraordinary circumstances?
No more than 3 cleavage-stage embryos or more than 2 blastocytes (usually 5-6 days after cell fertilization)
How many embryos (2-3 days after cell fertilization) can be transferred in females 38-40 in the absence of extraordinary circumstances?
No more than 4 cleavage-stage embryos or more than 3 blastocytes
How many embryos (2-3 days after cell fertilization) can be transferred in females > 40 in the absence of extraordinary circumstances?
No more than 5 cleavage-stage embryos or more than 3 blastocytes
What can acupuncture do for male infertility?
Increased motility of sperm. Increase number and percentage of health sperm. Improved quality and structural integrity of sperm
What can acupuncture with IVF do for female infertility?
Increase blood perfusion to uterus. Improve lining of uterus; normalize ovulation. Relax patients and reduce stress. 30-60 minutes before embryo transfer and after
