CHAPTER 44 female infertility Flashcards
What is infertility?
the inability to conceive within 12 months with regular coitus
It is estimated that infertility affects how many couples in America?
one in seven couples
regarding to infertility _____% of the cases are attributable to femal, _____% to the male, and the remaining ____% are combined or unexplained factors
40% female
40% male
20% unexplained
Infertility has been divided into what 6 causes?
- Cervical
- endometrial/uterome
- tubal
- ovulatory
- peritoneal
- male factor causes
What are the 3 male factor causes of infertility?
- inadequate number and decreased motility of sperm
- obstruction of vas deferens
- scrotal varioceles
What is the role of the cervix?
to provide a nonhostile environment to harbor sperm
The cervix secretes ______ and ________ that holds sperm?
mucous and crypts
What test is done to evaluate the cervical mucus and when is it done?
postcoital test and is performed within 24 hours of intercourse
When doing a postcoital test how is the cervical mucous evaluated and what are they looking for?
by aspirating the mucous from the cervix and under microscope looking for the number and motility of the sperm
ultrasound is used to evaluate the cervical length during pregnancy to assess for what?
cervical incompetence
In a non-gravid uterus what is difficult to assess?
the length and any opening of the cervix is hard to assess
What can be used to evaluate the internal os diameter?
hysterosalpingography
A measurement of less than 1 mm may indicate?
cervical stenosis
What are the sonographer two main objectives when evaluating a uterus?
- to assess the structural anatomy
- to assess the endometrium
(assessing for structural anatomy refers to evaluating the shape and echogenicity)
congenital uterine anomalies occur in _____% of women
.5-1%
Congenital uterine anomalies are the result of ?
defects in mullerian duct development, fusion or resorption
Congenital uterine anomalies are associated with ?
renal anomalies
The congenital anomalies most easily assessed with ultrasound are evaluations for?
bicornuate uterus and uterus didelphys
didelphys and bicornuate utereus are not usually associated with?
fertility problems or complications
what is the uterine anomaly that is associated with high incidence of fertility?
septate uterus
In the case of the septate uterus what causes the problem for implantation?
septum
in septate uterus if the pregnancy implants along the septum the pregnancy is at risk of what?
failure because of inadequate blood supply from the septum
On ultrasound how does the septate uterus appear?
as two endometrial cavities without a fundal notch
on ultrasound how does the bicornuate and didelphys uterus appear?
two endometrial cavities, a wide uterine body and a fundal notch
What is the difference sonographically between the septate uterus and the bicornuate/ didelphys uterus?
septate has no fundal notch
What is the t shaped uterus caused by ?
exposures to diethylstilbestrol in utero (DES)
What was DES used for in 1950’s to 1970’s?
to treat threatened abortion
patients with exposure of DES is at risk for?
cervical incompetence
What other imaging methods are better suited to evaluate the wide range of uterine anomalies?
MRI HSG
3d ultrasound provides the ability to view ?
the coronal plane that 2D is unable to obtain
What diagnosis does the coronal plan allow?
diagnosis of septate uterus vs. bicornuate uterus
what is measured throughout the menstrual cycle to look for appropriate changes/
endometrium
After ovulation, ________ is secreted by the corpus luteum?
progesterone
when does the secretion of progesterone begin?
the secretaory phase of the endometrial cycle
during the secretory phase, the endometrium becomes thickened and very echogenic as a result of ?
stromal edema, and there is loss of the triple line sign
The endometrial lining may be thinner than expected in ?
there is not enough progesterone produced in the luteal phase
The lack of progesterone production is know as?
“Luteal Phase Deficiency”
Luteal phase deficiency has been associated with?
infertility and early pregnancy loss
What are 2 other things that can make the endometrium appear irregular or more echogenic than normal?
submucosal fibroids or polyps
Describe fibroid:
broad base, more isoechoic to the uterine myometrium and tend to have circumferential flow around them
What has circumferential flow?
submucosal fibroid
_________ has a narrow base attachement to the endometrium(stalk).
polyps
What feeds the polys?
vascular pedicle
what two things can impede implantation and if found can be removed to enhance fertility?
fibroids and polyps
what is used to evaluate the uterine cavity for synechiae?
SIS
What are synechiar?
scars from uterine trauma
How are synechiae typically seen on ultrasound?
linear strands of tissue extending rom one wall of the uterine cavity to the other.
Fallopian tubes can be examined by ultrasound for ?
hydrosalpinx and to assess patency
How is tubal patency assessed?
by injecting saline into the tube and looking for spillage of fluid into the cul-de-sac or by using contrast to evaluate spillage
Before ultrasound what are the two non surgical methods of assessing patency?
Rubin’s test and hysterosalpingography (HSG)
Describe Rubin test?
involves insufflation of the fallopian tube with carbon dioxide gas
Describe HSG?
inserting a catheter trhough the cervix and then injecting contrast media to assess the uterine cavity and fallopian tubes anatomy under x-ray imaging
during ovarian follicular phase what size should follicles measure?
less than 5 mm in diameter
The dominant follicle will grow at a rate of ?
2 to 3 mm/day
What is the average diameter of a dominant follicle?
2.2 cm
What are the sonographic findings associated with ovulation?
echoes within the fluid left behind or free fluid in the peritoneal cavity from the rupture of the dominant follicle
What is the best predicator of ovulation and why?
the basal body temperature because the basal body temp will rise after ovulation
what one condition that can inhibit the release of FSH and LH ?
polycystic ovarian syndrome
PCOS often presents with the clinical triad of?
- oligomenorrhea
- hirsutism
- obesity
With PCOS what happens to the follicles?
They being to grow but do not develop normally
With PCOS the immature follicles continue to produce _______ and _______?
estrogen; androgen
*this production inhibits the pituitary glands function and prevents normal ovulation
What are suggested causes of PCOS?
obesity, diabetes and thyroid, adrenal or pituitary gland dysfuntion
What hormones does the pituitary gland produce?
LH & FSH
In PCOS, when obesity is a factor more _________ is produced leading to a _________ production of FSH and LH which results in an abnormal cycle
estrogen, decreased
what two ways may PCOS present sonographically?
- The ovary is round with multiple small immature follicles on the periphery described as “string of pearls”
- The ovary may appear normal
Peritioneal factors may be the cause for as many as _____% of infertility cases
25%
what are 2 peritoneal factors?
adhesions and endometriosis
what are adhesions?
bands of scar tissue that can obstruct the fimbrated end of the fallopian tube
Sometimes fluid will collect in between these adhesions (fimbrated end of fallopian tube), resulting in _____ _____ ____.
peritoneal inclusion cyst
what is endometriosis caused by ?
the ectopic placement of endometrial tissue outside the uterus
what is the gold standard for evaluating the pelvic adhesions and endometriosis?
laparoscopy
What are endometriomas?
blood filled cyst with endometrial tissue lining the cyst wall
Endometriosis involving the ovary can lead to the formation of?
endometriomas
Endometriomas typically appear sonographically as?
cysts with homogenous low amplitude internal echoes
what is the treatment in which ovarian stimulation is achieved in a controlled setting?
Ovarian Induction Therapy
what is the first step in the process of ovarian induction therapy?
obtain a baseline endovaginal ultrasound of the ovaries to rule out an ovarian cyst and assess for the presence of a dominant follicle
Why is it important to assess an ovarian cyst?
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
If serum estradiol is elevated and a large ovarian cyst is present what would be the treatment?
oral contraceptives may be indicated to suppress follicular activity before starting ovarian stimulation therapy
Ovarian induction therapy is usually accomplished by administering ?
clomiphene citrate (clomid) or human menopausal gonadotropin(pergonal) ; 3 to 5 in normal menstrual cycle
The administration of clomid and pergonal is expected to result in?
enlargement of multiple follicles compared with a single dominant follicle in naturally occurring menstrual cycle.
once ovarian induction therapy is started, what day is ultrasound used to monitor number and size of follicles?
8 to 14 of menstrual cycle
When evaluating follicles you must document all follicles greater than _____ cm.
1
The optional mean measurement of a follicle is between ___ and ____mm
10-20
A normal endometrial response associated with ovarian stimulation is an increasing thickness form
___ to ____mm to___ to ____mm
2-3
12-14
a endomentrium thickness less than _____ and an abnormal sonographic patter is associated with_____?
less than 8mm; decreased fertility
what is vitro fertilization
method of fertilizing the human ova outside the body
vitro fertilization the oocytes are fertilized in a dish for how long?
48 to 72 hours before transferred into the uterus
vitro fertilization: the placement of the embryo is considered to be withing ___ to ___cm of the apex of the fundus
1-1.5cm (15mm)
what are the success rates per cycle for both GIFT and ZIFT ?
22 to 28%
what is a technique used to treat male factor infertility?
intrauterine insemination
what are the complications associated with assisted reproductive technology?
ART: include ovarian hyperstimulation syndrome
OHS: multiple gestation, and ectopic pregnancy
What is OHS? and what size will ovaries measure?
syndrome that present sonographically as enlarged ovaries with multiple cysts, abdominal ascities and pleural effusion; 5-10 cm
OHS will present with what clinical indications?
leg edema, ascities, pleural effusion, hypotension and polycythema
what percent of vitro fertilization result in multiple gestations?
25%
