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2nd Year GYN > Chapter 44 female infertility > Flashcards

Chapter 44 female infertility Flashcards

1
Q

What is infertility?

A

the inability to conceive within 12 months with regular coitus

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2
Q

It is estimated that infertility affects how many couples in America?

A

one in seven couples

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3
Q

regarding to infertility _____% of the cases are attributable to femal, _____% to the male, and the remaining ____% are combined or unexplained factors

A

40% female
40% male
20% unexplained

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4
Q

Infertility has been divided into what 6 causes?

A
  1. Cervical
  2. endometrial/uterome
  3. tubal
  4. ovulatory
  5. peritoneal
  6. male factor causes
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5
Q

What are the 3 male factor causes of infertility?

A
  1. inadequate number and decreased motility of sperm
  2. obstruction of vas deferens
  3. scrotal varioceles
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6
Q

What is the role of the cervix?

A

to provide a nonhostile environment to harbor sperm

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7
Q

The cervix secretes ______ and ________ that holds sperm?

A

mucous and crypts

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8
Q

What test is done to evaluate the cervical mucus and when is it done?

A

postcoital test and is performed within 24 hours of intercourse

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9
Q

When doing a postcoital test how is the cervical mucous evaluated and what are they looking for?

A

by aspirating the mucous from the cervix and under microscope looking for the number and motility of the sperm

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10
Q

ultrasound is used to evaluate the cervical length during pregnancy to assess for what?

A

cervical incompetence

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11
Q

In a non-gravid uterus what is difficult to assess?

A

the length and any opening of the cervix is hard to assess

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12
Q

What can be used to evaluate the internal os diameter?

A

hysterosalpingography

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13
Q

A measurement of less than 1 mm may indicate?

A

cervical stenosis

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14
Q

What are the sonographer two main objectives when evaluating a uterus?

A
  1. to assess the structural anatomy
  2. to assess the endometrium
    (assessing for structural anatomy refers to evaluating the shape and echogenicity)
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15
Q

congenital uterine anomalies occur in _____% of women

A

.5-1%

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16
Q

Congenital uterine anomalies are the result of ?

A

defects in mullerian duct development, fusion or resorption

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17
Q

Congenital uterine anomalies are associated with ?

A

renal anomalies

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18
Q

The congenital anomalies most easily assessed with ultrasound are evaluations for?

A

bicornuate uterus and uterus didelphys

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19
Q

didelphys and bicornuate utereus are not usually associated with?

A

fertility problems or complications

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20
Q

what is the uterine anomaly that is associated with high incidence of fertility?

A

septate uterus

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21
Q

In the case of the septate uterus what causes the problem for implantation?

A

septum

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22
Q

in septate uterus if the pregnancy implants along the septum the pregnancy is at risk of what?

A

failure because of inadequate blood supply from the septum

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23
Q

On ultrasound how does the septate uterus appear?

A

as two endometrial cavities without a fundal notch

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24
Q

on ultrasound how does the bicornuate and didelphys uterus appear?

A

two endometrial cavities, a wide uterine body and a fundal notch

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25
Q

What is the difference sonographically between the septate uterus and the bicornuate/ didelphys uterus?

A

septate has no fundal notch

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26
Q

What is the t shaped uterus caused by ?

A

exposures to diethylstilbestrol in utero (DES)

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27
Q

What was DES used for in 1950’s to 1970’s?

A

to treat threatened abortion

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28
Q

patients with exposure of DES is at risk for?

A

cervical incompetence

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29
Q

What other imaging methods are better suited to evaluate the wide range of uterine anomalies?

A

MRI HSG

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30
Q

3d ultrasound provides the ability to view ?

A

the coronal plane that 2D is unable to obtain

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31
Q

What diagnosis does the coronal plan allow?

A

diagnosis of septate uterus vs. bicornuate uterus

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32
Q

what is measured throughout the menstrual cycle to look for appropriate changes/

A

endometrium

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33
Q

After ovulation, ________ is secreted by the corpus luteum?

A

progesterone

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34
Q

when does the secretion of progesterone begin?

A

the secretaory phase of the endometrial cycle

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35
Q

during the secretory phase, the endometrium becomes thickened and very echogenic as a result of ?

A

stromal edema, and there is loss of the triple line sign

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36
Q

The endometrial lining may be thinner than expected in ?

A

there is not enough progesterone produced in the luteal phase

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37
Q

The lack of progesterone production is know as?

A

“Luteal Phase Deficiency”

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38
Q

Luteal phase deficiency has been associated with?

A

infertility and early pregnancy loss

39
Q

What are 2 other things that can make the endometrium appear irregular or more echogenic than normal?

A

submucosal fibroids or polyps

40
Q

Describe fibroid:

A

broad base, more isoechoic to the uterine myometrium and tend to have circumferential flow around them

41
Q

What has circumferential flow?

A

submucosal fibroid

42
Q

_________ has a narrow base attachement to the endometrium(stalk).

A

polyps

43
Q

What feeds the polys?

A

vascular pedicle

44
Q

what two things can impede implantation and if found can be removed to enhance fertility?

A

fibroids and polyps

45
Q

what is used to evaluate the uterine cavity for synechiae?

A

SIS

46
Q

What are synechiar?

A

scars from uterine trauma

47
Q

How are synechiae typically seen on ultrasound?

A

linear strands of tissue extending rom one wall of the uterine cavity to the other.

48
Q

Fallopian tubes can be examined by ultrasound for ?

A

hydrosalpinx and to assess patency

49
Q

How is tubal patency assessed?

A

by injecting saline into the tube and looking for spillage of fluid into the cul-de-sac or by using contrast to evaluate spillage

50
Q

Before ultrasound what are the two non surgical methods of assessing patency?

A

Rubin’s test and hysterosalpingography (HSG)

51
Q

Describe Rubin test?

A

involves insufflation of the fallopian tube with carbon dioxide gas

52
Q

Describe HSG?

A

inserting a catheter trhough the cervix and then injecting contrast media to assess the uterine cavity and fallopian tubes anatomy under x-ray imaging

53
Q

during ovarian follicular phase what size should follicles measure?

A

less than 5 mm in diameter

54
Q

The dominant follicle will grow at a rate of ?

A

2 to 3 mm/day

55
Q

What is the average diameter of a dominant follicle?

A

2.2 cm

56
Q

What are the sonographic findings associated with ovulation?

A

echoes within the fluid left behind or free fluid in the peritoneal cavity from the rupture of the dominant follicle

57
Q

What is the best predicator of ovulation and why?

A

the basal body temperature because the basal body temp will rise after ovulation

58
Q

what one condition that can inhibit the release of FSH and LH ?

A

polycystic ovarian syndrome

59
Q

PCOS often presents with the clinical triad of?

A
  1. oligomenorrhea
  2. hirsutism
  3. obesity
60
Q

With PCOS what happens to the follicles?

A

They being to grow but do not develop normally

61
Q

With PCOS the immature follicles continue to produce _______ and _______?

A

estrogen; androgen

*this production inhibits the pituitary glands function and prevents normal ovulation

62
Q

What are suggested causes of PCOS?

A

obesity, diabetes and thyroid, adrenal or pituitary gland dysfuntion

63
Q

What hormones does the pituitary gland produce?

A

LH & FSH

64
Q

In PCOS, when obesity is a factor more _________ is produced leading to a _________ production of FSH and LH which results in an abnormal cycle

A

estrogen, decreased

65
Q

what two ways may PCOS present sonographically?

A
  1. The ovary is round with multiple small immature follicles on the periphery described as “string of pearls”
  2. The ovary may appear normal
66
Q

Peritioneal factors may be the cause for as many as _____% of infertility cases

A

25%

67
Q

what are 2 peritoneal factors?

A

adhesions and endometriosis

68
Q

what are adhesions?

A

bands of scar tissue that can obstruct the fimbrated end of the fallopian tube

69
Q

Sometimes fluid will collect in between these adhesions (fimbrated end of fallopian tube), resulting in _____ _____ ____.

A

peritoneal inclusion cyst

70
Q

what is endometriosis caused by ?

A

the ectopic placement of endometrial tissue outside the uterus

71
Q

what is the gold standard for evaluating the pelvic adhesions and endometriosis?

A

laparoscopy

72
Q

What are endometriomas?

A

blood filled cyst with endometrial tissue lining the cyst wall

73
Q

Endometriosis involving the ovary can lead to the formation of?

A

endometriomas

74
Q

Endometriomas typically appear sonographically as?

A

cysts with homogenous low amplitude internal echoes

75
Q

what is the treatment in which ovarian stimulation is achieved in a controlled setting?

A

Ovarian Induction Therapy

76
Q

what is the first step in the process of ovarian induction therapy?

A

obtain a baseline endovaginal ultrasound of the ovaries to rule out an ovarian cyst and assess for the presence of a dominant follicle

77
Q

Why is it important to assess an ovarian cyst?

A

b/c if cyst measuring greater that 2 cm is detected, it could represent persistent follicular activity that could interfere with response to ovarian stimulation medication

78
Q

If serum estradiol is elevated and a large ovarian cyst is present what would be the treatment?

A

oral contraceptives may be indicated to suppress follicular activity before starting ovarian stimulation therapy

79
Q

Ovarian induction therapy is usually accomplished by administering ?

A

clomiphene citrate (clomid) or human menopausal gonadotropin(pergonal) ; 3 to 5 in normal menstrual cycle

80
Q

The administration of clomid and pergonal is expected to result in?

A

enlargement of multiple follicles compared with a single dominant follicle in naturally occurring menstrual cycle.

81
Q

once ovarian induction therapy is started, what day is ultrasound used to monitor number and size of follicles?

A

8 to 14 of menstrual cycle

82
Q

When evaluating follicles you must document all follicles greater than _____ cm.

A

1

83
Q

The optional mean measurement of a follicle is between ___ and ____mm

A

10-20

84
Q

A normal endometrial response associated with ovarian stimulation is an increasing thickness form
___ to ____mm to___ to ____mm

A

2-3

12-14

85
Q

a endomentrium thickness less than _____ and an abnormal sonographic patter is associated with_____?

A

less than 8mm; decreased fertility

86
Q

what is vitro fertilization

A

method of fertilizing the human ova outside the body

87
Q

vitro fertilization the oocytes are fertilized in a dish for how long?

A

48 to 72 hours before transferred into the uterus

88
Q

vitro fertilization: the placement of the embryo is considered to be withing ___ to ___cm of the apex of the fundus

A

1-1.5cm

89
Q

what are the success rates per cycle for both GIFT and ZIFT ?

A

22 to 28%

90
Q

what is a technique used to treat male factor infertility?

A

intrauterine insemination

91
Q

what are the complications associated with assisted reproductive technology?

A

ART: include ovarian hyperstimulation syndrome
OHS: multiple gestation, and ectopic pregnancy

92
Q

What is OHS? and what size will ovaries measure?

A

syndrome that present sonographically as enlarged ovaries with multiple cysts, abdominal ascities and pleural effusion; 5-10 cm

93
Q

OHS will present with what clinical indications?

A

leg edema, ascities, pleural effusion, hypotension and polycythema

94
Q

what percent of vitro fertilization result in multiple gestations?

A

25%

2nd Year GYN (9 decks)

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