Chapter 9 - Infertility Flashcards by Rachael Garland

infertility affects

about 10%-15% of the reproductive-age population

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Subfertility:

prolonged time to conceive

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Sterility:

inability to conceive

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A normal couple has

has 20% chance to conceive each ovulatory cycle

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Diagnosis and treatment of infertility require

physical, emotional, and financial investment

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Causes:

20% idiopathic (unexplained)
Of the other 80%:
40% female
40% male
20% factors in both partners

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Female infertility

Congenital or developmental factors-surgical reconstruction
Hormonal and ovulatory factors
Tubal/peritoneal factors
Uterine factors
Vaginal-cervical factors - Isoimmunization

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Anovulation

not ovulating

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Primary anovulation:

caused by a pituitary or hypothalmic hormone disorder (ex. congenital adrenal hyperplasia) (usually can’t be fixed)

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Secondary anovulation:

relatively common caused by disruption of the hypothalmic pituitary ovarian axis (can be fixed, usually emotional stress)

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Factors that can make a woman infertile

Menopause before 40
Obesity
PCOS
Amenorrhea after BCP-rare
Increased prolactin level-medications, stress, surgery
Radiation,chemo

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PCOs

physical ovarian syndrome - not ovulating after 6 months after coming off of birth control pills

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Tubal/Peritoneal Factors

Motility of tube and fimbriated end affected by infections, adhesions, scarring, tumors
Chlamydia
Surgery-ruptured appy, trauma surgery
Endometriosis
(STDs can seal tubes shut)

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Uterine Factors

Bicornuate uterus
Vagina divided by septum
Asherman syndrome

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Asherman syndrome:

uterine adhesions or scar tissue. Can be form too vigorous scrapping with elective abortion or miscarriage

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Vaginal-Cervical Factors

Vaginal fluid acidic (pH 4-5)
Cervical mucous normally alkaline pH(7 or >)
pH can be affected by vaginal cervical infections (bacterial vaginosis), blood, pathogenic bacteria, irritants such as IUD, polyp, antibiotics, diabetes, severe emotional stress

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male infertility can be caused by structural and hormonal disorders

Undescended testes (can get fixed as a kid)
Hypospadias
Varicocele (varicose vein of the scrotum)
Low testosterone levels
Azoospermia: no sperm cells produced
Oligospermia: few sperm cells produced
Substance abuse

Azoospermia:

no sperm cells produced

Oligospermia:

few sperm cells produced

Substance abuse

Male Infertility

Mumps - after puberty more likely to be infertile
Genetics
Endocrine disorders
STI’s
Exposure to radiation

Considerations

Religious
Cultural
Ethnic
Cost
Insurance coverage
Emotional stress
(most couples won't see fertility specialist for 1 year)

Diagnostic test for female infertility

Detection of ovulation
Hormone analysis
Ultrasonography
Hysterosalpingography (die in tube)
Hysteroscopy 
Laparoscopy (look in)
Timed endometrial biopsy

Detection of ovulation-

basal boy temperature, cervical mucous characteristics, endometrial biopsy, pelvic ultrasound

Serum progesterone level-

need sufficient amount to accommodate implantation and sustain pregnancy

Hormone Analysis

``` Levels of : Prolactin Follicle stimulating hormone (FSH) Luteinizing hormone (LH) Estradiol (E2) Progesterone Thyroid studies ```

Ultrasound

Can be abdominal or transvaginal Assess for: fibroid tumors, ovarian cysts, follicular development, uterine cavity (most women 1st transvaginally)

Hysterosalpingography

Contrast through cervix (dye, can flush tubes out with dye) | Assess for : congenital defects, endometrial polyps, PID, scar tissue, adhesions

Hysteroscopy

Scope through cervix to view uterine cavity

Timed Endometrial Biopsy

Scheduled 2-3 days before expected menses Histological exam Expect tissue to be dated with respect to normal menstrual development

Laparoscopy

General or local anesthesia | Able to view pelvic structures intraperitoneally

Assessment of male infertility

Semen analysis- Ultrasonography-scrotal US, abnormalities in scrotum and spermatic cord (ph 7.2 or higher, viscosity, density - more than 20 million per ml, motility)

Assessment of the couple

Postcoital test (PCT) sample from cervical OS within several hours after intercourse evidence is lacking in validity of test

Plan of care and interventions

``` Psychosocial Nonmedical-weight loss, high scrotal temp, less alcohol, smoking cessation, Herbal alternative measures-see list 204 Medical Surgical ```

Medical

Clomid, human menopausal gonadotropin, human chorionic gonadotropin Metformin and dexamethasone can potentiate clomid for anovulation in women who have PCOD >25% of multiples with meds

--> clomid

makes women release more eggs

Assisted therapy -

IVF - ET, ICSI, PGD, GIFT, ZIFT

IVF- ET:

IN Vitro Fertizlization-Embryo Transfer- Ovarian stimulation using Rx collected midcycle using needle, fertilized with sperm in a dish for up to 6 days then transferred to uterus using US.

ICSI-

Intracytoplasmic sperm injection-introduce sperm directly into egg-can use poor quality sperm or less sperm

PGD-

Preimplantation genetic diagnosis-genetic testing before impantation of IVF embryo

GIFT-

Gametic intrafallopian transfer-similar to IVF-eggs induced and harvested, sperm collected-sperm and egg placed in uterine tube allowing for natural fertilization-<1% ART use this technique

ZIFT-

Zygote intrallopian transfer-similar to GIFT except IVF then zygote is placed in uterine tube-<1% of all ART

Donation

``` Oocyte donation Embryo donation Embryo Host (surrogate) Therapeutic Donor Insemination (TDI)-normal female fertility TDI works about 70% of the time Adoption ```