4 Infertility and Abortion Flashcards
Capacity to conceive and produce offspring
Fertility
The probability of achieving a pregnancy in one menstrual cycle
Fecundability
THis is a more accurate descriptor b/c it recognizes varying degrees of infertility
Diminished capacity to conceive despite frequent coitus
Infertility
Subfertility may be a more appropriate description for most couples
Inability to conceive offspring
Sterility
Used after sterilization procedure, specific illness, exposure, or genetic condition
____% of couples will conceive in the first 6 months of unprotected sex
80%
85-90% during the first 12 months
Fecundability decreases as…
A woman ages due to declining quantity and quality of oocytes
When is evaluation of infertility indicated?
Inability to conceive after 12 months of unprotected intercourse for women ≤35
If >35, it’s after 6 months
What are the causes of infertility?
Male factor = 8%
Female factor = 37%
Combined = 35%
Unknown = 5%
4 main categories of male factor infertility
Endocrine and systemic disorders
Primary testicular defects in spermatogenesis
Sperm transport disorders
Idiopathic male infertility
Clinical semen findings for infertility
Low sperm concentration
Absent sperm
Motility issues
Morphology issues
How are semen samples obtained for analysis
Masturbation sample in the office 🏥🍆💦
2-7 days of sexual abstinence to ensure accurate concentration of sample
2 samples taken 1-2 weeks apart
What are we testing for in semen analysis?
Volume Sperm concentration Total sperm number Sperm morphology Vitality Progressive motility Total
What is Klinefelter’s syndrome
XXY male
Low IQ, tall, poor muscle tone, reduced sex characteristics, man boobs, small testes/infertility
Most common congenital abnormality causing primary hypogonadism
Klinefelter’s syndrome
10-15% of infertile men with azoospermia and small testes
Main contributing factors in female-factor infertility
Ova
Patent Oviduct
Anatomic abnormalities of the uterus
Complications of ovulation that can lead to infertility
PCOS
Thyroid dysfunction
Hyperprolactinemia
Cutaneous signs of hyperandrogenism
Oligomenorrhea/amenorrhea
Obesity/insulin resistance
Polycystic ovaries on U/S
Polycystic Ovarian Syndrome
Relationship between thyroid and fertility
Both hypo and hyperthyroidism can disrupt normal ovulation
1/8 of women will develop thyroid dysfunction in their lifetime
Can lead to oligomenorrhea/amenorrhea
Relationship between elevated prolactin levels and infertility
High prolactin states include breastfeeding, breast stimulation/intercourse, extreme exercise, and meds (RISPERIDONE**)
Serum prolactin should be repeated if elevated with pt ed regarding the above
If levels persist - evaluate for pituitary adenoma with MRI
Treating PCOS to increase fertility
Proper diet and exercise education
Provera cycling
Metformin
Clomiphene (50 mg PO x 5 days beginning on cycle day 5)
Treating thyroid disorders to improve fertility
Use pregnancy safe options
Hyper = PTU
Hypo = Levothyroxine
Treating hyperprolactinemia to improve fertility
Bromocriptine - safe in pregnancy but d/c once pregnancy achieved
How does Clomiphene work?
Selective Estrogen Receptor Modulator (SERM)
Induces ovulation in 60-85% of anovulatory women
Twins 7-9%
Triplet rate is 0.3%
Serious short term complication of Clomiphene
Ovarian hyperstimulation
Can lead to thromboembolic events
Tubal factors that affect fertility
Occluded oviduct (untreated STI/PID, hydrosalpinx, mucous, anatomic abnormalities)
Injury/surgery to oviduct (salpingectomy, previous ectopic pregnancy)
Tubal factors affecting fertility can be ruled out with…
Hysterosalpingograpm (HSG)
Limitations to hysterosalpingogram
Not covered by most insurances (~$400)
Possibly painful
Evaluates for tubal patency but not function
Treatment for tubal factors in infertility
Surgical tubal repair (rare - high failure rates and risk of ectopic pregnancy)
IVF
Two most important questions to ask in cases of infertility?
Are you having regular menses?
How often are you having intercourse?
What is Spinnbarkeit?
Egg white cervical mucous that typically occurs during ovulation?
What is Mittelschmerz
Pain with ovulation
What medications are used for elective abortions
Misoprostol and Mifepristone
Effective 95-98% of the time
Risks:
• Retained products requiring D&C (2%)
• Infection - can give prophylactic abx
FDA approved up to 70 days (10 weeks) GA
What are the three surgical methods of elective abortion?
Suction D&C
Dilation and evacuation
Stimulation of labor
What is a spontaneous abortion?
A miscarriage
Pregnancy loss occurring prior to 20 weeks GA
Most common complication of pregnancy
What labs do you wanna run after a spontaneous abortion?
CBC
Rh type
HCG quantitative
Pelvic and transvaginal U/S
Most common cause of spontaneous abortion?
Abnormal karyotype - something is wrong with the embryo genetically
Usually occurs in the first trimester (specifically < 8 weeks)
What is a threatened spontaneous abortion?
Closed cervical os but bleeding in the presence of a (+) urine pregnancy test
What is an inevitable spontaneous abortion?
Open cervical os presenting with bleeding
What is a missed abortion?
Absent heartbeat without bleeding and a closed cervix
What is a “habitual aborted”
Three or more consecutive losses prior to 20 weeks
Risk of future SABs increases with each subsequent SAB
Common causes of recurrent abortions
Abnormal karyotype Uterine malformations Antiphospholipid antibody (Lupus) Chronic uncontrolled medical conditions Insufficient progesterone levels
