B8.001 Infertility: Evaluating the Infertile Couple Flashcards
infertility
<35 : no preg with timed intercourse for at least 1 year
>35: no preg with times intercourse for at least 6 mo
women > 40 qualify for immediate eval
relationship between maternal age and fertility/ aneuploidy/ live birth/ miscarriage
infertility increased with age, nearly exponential shape after 40
aneuploidy and miscarriage increases with age
chance of live birth decreases with age
prevalence of infertility
15% of couples
why might you do an earlier infertility workup
irregular periods severe endometriosis known problems with tubes or uterus known or suspected male subfertility maternal age > 39
general steps in pregnancy
- egg release (ovulation)
- sperm must reach egg (fertilization)
- fertilized egg travels through fallopian tube
- implantation of fertilized egg onto inside of uterus
causes of infertility
male only 8%
female only 33%
male and female 35%
unexplained 24%
general process of diagnosing infertility
both partners evaluated at the same time if possible H&P preconception counseling genetic screening diagnostic testing
components of infertility diagnostic evaluation
ovulatory function
ovarian reserve
uterine or fallopian tube abnormalities
semen analysis
components of ovulatory function testing
menstrual history basal body temp ovulation prediction kits US monitoring mid luteal progesterone
causes of WHO 1 infertility
stress
exercise
diet
causes of WHO 2 infertility
polycystic ovaries
hyperandrogenism
irregular menses
causes of WHO 3 infertility
fragile X
autoimmune
Turner’s
galactosemia
treatment of WHO 1 infertility
behavioral modification
gonadotropins
treatment of WHO 2 infertility
behavioral modifications
letrozole
treatment of WHO 3 infertility
hormone replacement therapy
donor oocytes
when would you consider ovarian reserve testing
>35 tobacco use prior ovarian surgery prior gonadotoxin exposure 1st degree relative w menopause < 40
how to test ovarian reserve
antimullerian hormone
CD3 FSH and estradiol
antral follicle count
how to evaluate uterine or fallopian tube abnormalities
MRI
hysterosalpingogram (HSG)
saline sonogram (SIS)
hysteroscopy / laparoscopy
effects of chlamydia on tubal infertility
causes a build up of scarring that can block the fallopian tube and prevent fertilization
tubal HSG findings in genital TB
specific: beaded tube golf club tube pipestem tube cobblestone tube leopard skin tube nonspecific: hydrosalpinx mucosal thickening peritubal adhesion
uterine HSG findings in genital TB
specific: T shaped uterus pseudounicornate uterus trifoliate uterus nonspecific: endometriosis syneciae distortion of uterine contour venous, lymphatic intravasation
how to assess male factors of infertility
semen analysis
- if abnormal: abstain 2-5 days and repeat
- if normal: assess frequency and timing of intercourse
workup for male factors of infertility
previous fertility/infertility sexual dysfunction GU anomaly previous GU surgeries toxic exposures occupation / lifestyle med/ psych illnesses
what to assess if semen analysis is abnormal
-optimize medical health
-optimize psychological health
-avoid toxins
-healthy lifestyle
IF STILL ABNORMAL
-T, PRL, E2, LH, FSH
-urology consult
oligospermia
low sperm concentration/ count
asthenospermia
low sperm motility
teratospermia
abnormal sperm morphology
steps of semen analysis
- confirm length of abstinence (2-5 days)
- produce semen sample
- liquification (<1 hr on benchtop, 15-30 min at 37C)
- basic semen analysis performed, viscosity noted
what can cause liquification problems
environment/ occupation
semen analysis parameters
volume > 1.5 mL pH 7.2-8.0 concentration > 15x10^6 motility >39% total motile > 40x10^6 vitality >75% morphology >4% normal WBC < 1x10^6
sperm morphology
head -acrosomal vesicle -nucleus tail -midpiece w mitochondria -flagellum
artificial insemination
intrauterine insemination
no male factor to mild male factor
used with natural cycles in combination with ovulation induction or superovulation
treatment of low sperm count
IUI (total motile > 10mil)
IVF (total motile < 10 mil)
ICSI (total motile < 10 mil)
treatment of low motility/ poor forward progression
NECA (adenosine analog)
IUI
treatment of anti-sperm antibodies
chymotrypsin/ galactose
IUI
chymotrypsin
media which aids in degradation of Ab/sperm complexes
breaks down proteins in ejaculate
galactose
media which prevents sperm from binding to Ig
treatment of poor liquefaction
chymotrypsin/ chymotrypsin inhibitor
IUI
varicocele
swelling of veins that drain the testicle
most common reversible cause of male infertility
infection and male infertility
some infections can interfere with sperm production or sperm health or can cause scarring that blocks the passage of sperm
some result in permanent testicular damage, but usually sperm can still be retrieved
examples of infections that can contribute to male infertility
epididymitis
orchitis
STIs: gonorrhea, HIV
retrograde ejaculation
semen enters the bladder during orgasm
caused by: diabetes, spinal injury, medications, surgery
medical causes of male infertility
anti sperm Abs undescended testicles hormone imbalances tumors blockage/transport tubule defect
semen without sperm or fructose
may indicate absence of the seminal vesicles, absence of the vas deferens in the areas of the seminal vesicles, or an obstruction at the level of the seminal vesicles
chromosomal/ genetic causes of male infertility
klinefelters (XXY)
CF (blockage/absence of sperm canal)
kallmann’s (hypogonadotropic hypogonadism)
kartagener’s (dysfunctional ciliated/flagellated cells)
medications that can lead to male infertility
testosterone replacement therapy long term anabolic steroid use cancer meds certain antifungals ulcer drugs
environmental causes of male infertility
industrial chemicals heavy metal exposures radiation or x-rays overheating the testicles occupation (sitting, outdoor, tight clothing)
treatments for female infertility
- ovulation induction or superovulation
- letrozole
- clomiphene citrate (SERM)
- gonadotropins - surgery
- correct uterine or tube abnormalities - intrauterine insemination
- male factor or unexplained - IVF
IUI
intrauterine insemination
TDI
therapeutic donor insemination
what is IUI
fertility treatments that uses catheter to place washed sperm directly into uterus
IVF
in vitro fertilization
what is IVF
eggs surgically removed from ovary sperm mixed with egg outside body fertilized egg (embryo) places into uterus
prevalence of IVF
<5% of all fertility treatments
treatment for unexplained infertility
clomid + IUI
treatment for PCOS infertility
letrozole
treatment for bilateral tubal occlusion infertility
IVF
preimplantation genetic diagnosis
direct testing of IVF embryos
typically for single, inherited genetic disease
preimplantation genetic screening
direct testing of IVF embryos for large scale chromosome abnormalities (trisomy, deletions, duplication)
recommended for advanced maternal age and recurrent pregnancy loss
impact of stress on chance of getting pregnant
controversial
stress reduction may improve fertility
preconception health
stop tobacco use no illicit drugs limit alcohol/caffeine maintain a healthy weight take vitamins (folic acid for women, antioxidants for men) get vaccinated Zika precautions
tobacco and fertility
smoking delays conception for more than a year
lowers egg count
increased risk of defects and miscarriage
lowers chance for success
in 3 months after cessation, sperm quality improves
marijuana and fertility
reduces sperm number and quality
reduces testosterone production
reduces number of eggs retrieved with IVF
increased risk of premature delivery
alcohol and fertility
3 glasses of wine per day impairs fertility in men
2 glasses of wine per day impairs fertility in females
decreases embryo quality
increases risk of FAS in children
caffeine and fertility
lower live birth rates with IVF
may inhibit egg maturation
not a clear association
recessive carrier screen
recommendations vary by ethnicity
blood test offered to all women pursuing pregnancy
1/30 caucasians are carriers for CF
recent technology can prevent rare genetic conditions in offspring
