Columbus: Infertility and ovulation induction Flashcards
Define infertility, fecundity, fecundability
One year of unprotected intercourse without conception
The probability the single cycle will lead to a life birth
The probability that a single cycle will result in a pregnancy
Who is at increased risk of ovarian insufficiency and should have ovarian reserve testing?
Greater than 35 years of age Anyone with unexplained infertility Prior ovarian surgery Anyone with poor response to gonadotropin stimulation Smokers Family history of premature menopause
What factors have led to a decreased the general fertility rate since 1950?
Later marriage
Use of improved contraception
Career before conception
Decreasing family size
How does increasing age decrease fertility?
Limited number of oocytes
Follicular hormone changes such as increased FSH, decreased inhibin and shorter follicular phase
Disordered meiotic spindle formation and function leading to increased aneuploidy
How can ovarian reserve be tested?
Day 3 FSH and estradiol
Clomiphene citrate challenge test (collect D3 FSH and estradiol, then repeat after completing Clomid cycle. Total FSH for both should be less than 26)
Ovarian volume
Antral follicle count (3-10 follicles less than 10 mm is low)
Anti-mullerian hormone
What are causes of male infertility?
Abnormalities in spermatogenesis
Obstruction of outflow tract
Abnormalities of hormone support of sperm production (such as increased prolactin which decreases testosterone)
Coital problems
What are causes and rates of infertility for couples?
Tubal and pelvic disease 35% Male factors 35% Ovulatory dysfunction 15% Unexplained 10% Unusual problems 5%
What are the causes and rates of female infertility?
Ovulatory dysfunction 40%
Tubal and pelvic disease 40%
Unexplained 10%
Unusual problems 10%
When is fertility evaluation recommended?
Those who have not conceived in 1 year
Women 35 years old or older who is not conceived at 6 months or earlier
Women with irregular periods or amenorrhea
Women with a history of pelvic inflammatory disease, endometriosis, or prior pelvic or abdominal surgeries
What is the effect of smoking on fertility?
Higher prevalence of infertility
Accelerated follicular loss
Gamete or embryo mutagenesis
Menstrual cycle abnormalities
What are the key components of the history for infertility evaluation?
Prior pregnancy outcomes
Medical history including PCOS, thyroid or pituitary disease
Surgical history including pelvic surgery and ovarian surgery
Gyn history including menstrual history and STI
Medications including NSAIDs and Aldactone
Substance abuse such as smoking, marijuana, cocaine, alcohol, caffeine
Environmental exposures such as toluene, herbicides, and fungicides
Family history including early menopause, birth defects and genetic abnormalities
What is the relative risk of an ovulation with BMI greater than 27?
Less than 17?
RR 3.1
RR 1.6
How does marijuana affect fertility?
Cocaine?
Inhibits GnRH pulsatility
Impairs spermatogenesis
What features of the physical exam are important for fertility evaluation?
BMI Hirsutism and acne Thyroid Breast discharge Pelvic exam including size of uterus and ovaries, cervical infection, tenderness or nodularity in the cul-de-sac
What preconceptual genetic screening is recommended for which ethnic groups?
Ashkenazi Jews: Hexosaminidase A (Tay Sachs, lysosomal storage disease)
African-American: hemoglobin electrophoresis (Sickle cell)
Mediterranean: MCV less than 80 then hemoglobin electrophoresis
European whites: CFTR gene mutation (cystic fibrosis)
