CM- Infertility Flashcards
What is a normal conception rate?
monthly conception rate [fecundability] is approximately 25%
[1/4 couples will conceive within a month of trying].
85% will conceive in a year
93% in 2 years
95% in 3 years
What is primary infertility?
- Inability of a couple to conceive after 1 year of sexual intercourse
- inability of a couple where the woman is over 35 to conceive within 6 months of trying
What is secondary infertility?
The female partner has conceived at least once before [even if it was a stillbirth or miscarriage] but now hasn’t been able to get pregnant in one year of trying
How does infertility change with increasing female age?
The peak age of fertility is 25 and then significant decline starts at 35.
20-30 = 1/10 women have infertility 30-40 = 1/6 women have infertility 40+ = 1/4 women have infertility
What are the most common causes of infertility by diagnosis?
- male factor 40%
- anovulation 30%
- tubal factor 15%
- pelvic factor [adhesions, endometriosis] 15%
- uterine factor
- cervical factor
- idiopathic
A woman presents to you complaining of infertility. When asked about her menses, she says she bleeds irregularly, about every 15 to 40 days.
Her basal body temperature charts are monophasic. What is the likely cause of the infertility?
Anovulation/ oligo-ovulation
What factors are used to assess ovarian function?
What 4 things point toward normal ovulation?
What 3 factors suggest anovulation/oligo-ovulation?
Normal ovulation:
- normal menses, reg cycle
- Mittelschmerz =cramping at day 14
- Biphasic basal body temp charts are indicative of a progesterone increase after ovulation
- prior pregnancy indicates the woman ovulated at one time
Possible disruption to normal ovulation:
- dymenorrhea
- prior exposure to chemo or radiation
- PCOS, hypogonadotrophic hypogonadism, POF [hyper, hypo]
What is the MOST reliable indicator of ovarian function?
Regular menstrual cycle
What are the lab tests that can evaluate ovarian function?
- Basal body temperature - if ovulating, it should be biphasic [increased temp with progesterone, but at that point you have missed ovulation]
- Sonogram - size/shape of uterus and ovaries, leiomyomas, antral follicle count
- Mid luteal phase progesterone [often used]
- LH ovulation kits- measure LH surge in urine so you can time intercourse for when you are ovulating
- Endometrial biopsy [not common]
- TSH - rule out hypothyroidism, hyperthyroidism
- prolactin - rule out hyperprolactinemia
- Testosterone/DHEAS to see if elevated androgens [PCOS]
- Ovarian reserve testing - FSH and estradiol at day 3 of the cycle if patient is older and you are worried about reserve.
A woman presents with a history of a prior gonorrhea infection. She has normal menses and regular cycles, but she is having trouble getting pregnant. What is the likely cause?
Fallopian tube dysfunction/pelvic factor
- history of pelvic infection
- pelvic pain [endometriosis]
- prior pelvic surgery [ovarian cysts, endometriosis, C-section, tuboplasty, appendix, bowel]
- family history of endometriosis
What are the 4 major factors that contribute to tubal dysfunction/pelvic factor causes of infertility?
- Prior pelvic infections [gonorrhea, chylamydia, PID, endometritis]
- pelvic pain [ endometriosis, dysmenorrhea]
- prior pelvic surgery
- gynecological = ovarian cysts, tuboplasty, endometriosis, C-section
- appendix, bowel - Family Hx of endometriosis [1 fam member =7x as likely to get tubal dysfunction]
A woman has a 4 year old girl. She and her husband have been trying to have a boy but she is having trouble getting pregnant. She is 29 and has been trying for a year.
When asked, she says her menses are regular. She has never had an STD or pelvic pain. On delivery of her first child, she had a C-section. What does this make you suspicious for as the cause of the infertility?
Pelvic surgery like C-section are an indication for tubal/pelvic factor of infertility
What tests can you do to check tubal/pelvic factors?
- Hysterosalpingogram [HSG] - inject dye in the uterus and it goes retrograde through the tubes. If the tubes are intact, there will be “spillage of dye” on both sides
- Laparoscopy & chromotubation [GOLD STANDARD] - can look for dilated tubes and Fitzhugh curtis adhesions that could be distrupting tubular function
What 5 things would make you suspicious that the cause of infertility was uterine?
- length and amount of menses [fibroids]
- history of D&C
- recurrent miscarriages
- IUD use [maybe secondary infection]
- prior pregnancy history
What are the 5 tests that you would want to do to evaluate uterine function?
- hysterosalpingogram
- hysteroscopy
- hysterosonogram
- pelvic US
- late luteal phase endometrial biopsy versus serum progesterone [gold standard for luteal phase defects]
