Common diagnosis Flashcards by Amanda S.

primary infertility definition - how long trying without getting pregnant?

In a woman with no prior conception,

12 months of attempting conception without success

85% of couples succeed in this time

Earlier investigation may be warranted in women over 35 years of age after 6 months of trying.

Earlier investigation recommended in some patients due to history: i.e. Tubal ligation, vasectomy, chemotherapy, age, genetic

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“Normal” couples have a fecundity approaching what percentage?

A. 5%

B. 20%***

C. 50%

D. 75%

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Etiology of Primary Infertility

(primarily OUTDAE)

Ovulatory Disorders
Uterine Factor
Tubal Factor
Diminished Ovarian Reserve
Age
Endometriosis

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Causes of Male factor infertility - genetic - 5 of them

Genetic:

Y-Microdeletion (deletions on Y chromosome)

Klinefelter syndrome (47, XXY) or other chromosomal condition

Congenital Bilateral Absence of the Vas (CF) - missing the vas deferens

Insensitivity to hormones (androgens), which include testosterone

Cryptorchidism (? Genetic)

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Y-Chromosome Microdeletions

(C olig)

Microdeletions of segments of the Y-Chromosome can lead to alterations of spermatogenesis

10-15% of men with oligospermia->azoospermia may be affected

AZFc (this is a deletion from the Y chromosome) ->Oligospermia

AZFa or AZFb (this is a deletion from the Y chromosome)->azoospermia (no sperm at all)

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male factor - Obstructive Azoospermia:

There is a missing or blocked connection in the epididymis, vas deferens or elsewhere in the reproductive tract that will not allow sperm to exit the body.

Causes:

Congenital

I.e.. CBAVD-Congenital absence of the vas deferens—(CF )

Surgical

Previous genital tract infection

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Obstructive Azoospermia: options?

Sperm may be able to be retrieved directly from the testicle by a reproductive urologist. Sperm aspiration

Only Tx. Option IVF/ICSI

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Nonobstructive Azoospermia:

No sperm is being produced due to a structural or functional defect in the testicle.

Causes:

Hormonal

Genetic

Testicular

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Nonobstructive Azoospermia: - options?

Possible to try surgical procedure to retrieve sperm—low chance for success

Medication may help..

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Klinefelter’s Syndrome, 47 XXY - what hormone is high?

Most common sex chromosome disorder

High FSH, low testosterone levels

Small testes

Azoospermia

Possible option of microTESE

Female body shape

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female factors

(OUTDAE)

ovulation disorders, uterine factor, tubal factor, diminished ovarian reserve (DOR), age, endomentrosis

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ovulation disorders

(PHHHL has ovulation disorders)

PCOS, Hypogonadotropic Hypogonadism (“hypohypo”), hypothyroidism, hyperprolactemia, luteal phase deficiency

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fibroids

benign (non-cancerous) tumors of the uterine muscle wall that can cause abnormal uterine bleeding. Also known as leiomyomas or myomas.

Classified by location.

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polyps - where are they found?

Uterine polyps are growths attached to the inner wall of the uterus that extend into the uterine cavity. Generally benign

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adenomysosis

(aden grows)

Endometrial tissue grows into the uterine muscle.

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mullerian anomalies - is it congenital?

Congenital disorder of the female reproductive tract.

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Uterine Anomalies:

Fibroids (muscle tumor)/myoma
Polyps

Adenomyosis

Mullerian anomalies

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Diagnostic Tests - uterine factors

Pelvic Ultrasound (transvaginal)

Hysterosalpingogram (HSG)

Saline Sonogram (SIS)

HyCoSy (vaginal ultrasound)

Hysteroscopy (HSC) (thin tube with camera)

MRI (not done at our clinic)

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tubal factors - most damaging cause?

Fallopian tubes are required for fertilization to occur within the body

Risk factors for tubal obstruction/disease:

Previous STD/PID - this is the worst

Previous surgery

Previous tubal sterilization (ligation)

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Endometriosis

Endometriosis is a condition in which endometrial tissue, which normally lines the uterus, develops outside of the uterine cavity in abnormal locations such as the ovaries, fallopian tubes, and abdominal cavity.

Symptoms:

Pelvic/Abdominal pain esp. w/menstrual bleeding or sex

Some asymptomatic

30% to 50% of infertile women have endometriosis.

Sometimes, endometriosis can grow inside your ovary and form a cyst (endometrioma).

treatment for preg with endometrosis is IVF

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age - why?

Fertility begins to decline at age 35

Fewer follicles (oocytes) remaining in ovary

Increased chromosomal abnormalities within the oocyte

Higher rates of aneuploid (chromosomally abnormal) embryos

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age - tests - same 5 tests

3 hormone, 2 ultrasound

Blood tests:

AMH (Anti Mullerian Hormone) - can be done at anytime

FSH /Estradiol(E2)

Ultrasound (transvaginal)

AFC (Antral follicle count)- to assess follicles (egg sacs)

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Diminished Ovarian Reserve (DOR)

DOR refers to accelerated ovarian aging resulting in reduced fertility

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unexplained infertility - what are the 4 things we test for to see what the problem is? this is both partners (SFOO is unexplained)

Diagnosis of exclusion after testing shows: Normal Semen Analysis Patent fallopian tubes and normal uterine cavity Normal Ovarian reserve testing Documentation of ovulation 30% of couples are diagnosed with "unexplained" infertility

Evalution of the Infertile Couple

Female: Hormonal Causes: Measure ovarian reserve Ovulation? Hormonal imbalance Structural Causes: Evaluation of Uterus and Ovaries Evaluation of the Fallopian tubes and uterine cavity Male Semen Analysis

Testing unexplained infertility - 4 tests - blood test and ultrasound?

Blood tests: AMH, FSH/E2 Ultrasound: Baseline transvaginal ultrasound Antral Follicle Count (AFC)

Other testing

Determine ovulatory status Ultrasound evaluation during cycle to assess follicular growth "Day 21" progesterone blood test If irregular menstrual cycles: Thyroid testing (blood test)-part of standard workup, all patients. Prolactin (if indicated)

Saline Infusion Sonogram (SIS) - what days of cycle to do this?

In office procedure, well tolerated Done between CD (cycle day) 5-12 (after bleeding, before ovulation) Sterile saline injected to distend the uterus Can detect abnormal growths inside the uterus, such as fibroids or polyps

Hysterosalpingogram (HSG)

HSG is an x-ray procedure used to see whether the fallopian tubes are patent (open) and if the inside of the uterus (uterine cavity) is normal. Also known as "the dye test" Done CD 5-12 (after bleeding, before ovulation) Iodine contrast (ensure no shellfish allergy) Can be performed at some SPRING facilities

HSG, cont. Tubal infection (Hydrosalpinx)

Hydrosalpinx- Hydrosalpinx is a composite of the Greek words ὕδωρ (hydōr – "water"[1]) and σάλπιγξ (sálpinx – "trumpet"[1]); its plural is hydrosalpinges. it's fluid in the tube You can't get rid of tubal infections Causes: Most common cause: Previous STI (Sexually transmitted infection)-ie. GC/Chlamydia. Other causes: Adhesion formation from surgery, endometriosis, cancer of the tube, ovary or other surrounding organs. Symptoms: Most asymptomatic, some have lower abdominal pain Treatment: Salpingectomy: Surgical removal of the fallopian tube (Uni (one) or Bi (both) tubes). If left in place, the fluid can leak into the uterus which decrease pregnancy rates by ~ half.

HyCoSy Hysterosalpingo Contrast Sonography (hycosy foam)

Newer procedure to assess uterine cavity & tubal patency Offering for self-pay patients Done CD 5-12 (after bleeding, before ovulation) Patient to have empty bladder Must do HPT day of to ensure no pregnancy. Normal to have light spotting/liquid - foam seen post procedure

Antibiotic Prophylaxis for tubal evaluation procedures

Most uterine/tubal evaluations carry a low risk of causing future infection, therefore the standard of care is NOT to prescribe antibiotics for these procedures unless indicated. Indications for prescribing Doxycycline 100mg BID (twice daily) x 5days: Patient with a history of pelvic inflammatory disease (PID)* Findings of hydrosalpinx on exam Indications for prescribing Doxycycline 100mg BID x 1 day Spring patients completing tubal evaluation outside of Spring Fertility. This is in case a hydro if found on exam. If hydro is found, they will need 4 days additional antibiotics prescribed. *Prior to scheduling HSG/HyCoSy/SIS, PN/RN must ask patient if any history of PID. If yes, antibiotic should be prescribed and patient should begin morning of procedure.

Hysteroscopy

Hysteroscopy (HSC) is a minimally invasive surgical procedure Camera is inserted into the vagina and through the cervix to get a detailed visualization of the uterine cavity. Normally done under anesthesia, in the OR. This procedure can find and remove polyps, fibroids, scar tissue using small instruments inserted through the hysteroscope.

Semen Analysis

Parameters (Normal): Concentration (Count) ≥ 15 x106/ml Motility (movement) ≥40% Morphology (Shape) ≥4% Volume ≥1.5mls Color Whitish, gray, opalescent Viscosity Normal liquefaction Complete in 30 min agglutination 0 presence of round cells and leukocytes : ≤ 1 x 106/ml Forward progression 2-4 most important in sperm test - TMC

female factors for infertility (infertility is OUTDAE)

(40%) - ovulation disorders, uterine factor, tubal factor, diminishede ovarian reserve, age, endometrosis

male factors for infertility

(30%) usually all about the sperm - azo, oliog, aztheno, terato

male factor - oligosperimia (olga is small)

refers to decreased sperm concentration

male factor - teratospermia

abnormal morphology (shape of sperm)

male factor - asthenospermia (start with motility)

abnormal motility

male factor - oligasthenospermia

very common -low count with reduced motility

male factor - oligoasthenoteratozospermia

most common - sperm count, movement, shape all have abnormal parameters

male factor - azospermia

absence of sperm

male factor - evaluation

urologist, blood tests

sperm keeps for

about a day

Polycystic Ovarian Syndrome (PCOS)

Affects 5-10% of women Menstrual irregularity Clinical or biochemical evidence of hyperandrogenism (hirsutism) Ultrasound evidence of polycystic ovaries

Hypogonadotropic Hypogonadism ("hypo hypo") - who gets it?

Lack of hormones that normally stim. The ovaries. ie. GnRH, FSH, LH. Ex. Female Athlete Triad: Anorexia, Amenorrhea and Osteoporosis

ovulatory disorders - 2 main ones (ovulation disorders are HH)

Hypothyroidism Hyperprolactinemia - too much prolactin (can be caused by pituitary tumor), or nipple stimulation (running, etc) "Luteal Phase deficiency" - corpus luteum is not functioning so progesterone level not as high as it should be

low sperm concentration = treatment

sperm cryo and banking, surgical retrieval techniques, ICSI, sperm donor

azoospermia - treatment

surgical retrieval, sperm cryo and banking, surgical retrieval techniques, ICSI, sperm donor

cIVF

c = conventional. It's just putting the egg and sperm together and letting them mix naturally

ICSI

ixie - injecting sperm into egg to create an embryo

What are six etiologies of Primary Infertility in the female? (infertility in women is outdae)

uterine, tubal, diminished ovarian reserve, endomentrosis, and age

Define Azoospermia?

no sperm

Review the main difference between: Obstructive and Nonobstructive Azoospermia.

one is an obstruction and the other is unknown

Name the two tests SPRING recommends to evaluate ovarian reserve.

AMH (anti mullerian) and AFC (antro-follicle count)

What are two tests that can advise on tubal patency?

Hysterosalpingography (HSG) or hysterosalpingo-contrast sonography (HyCoSy)

why would an HSG be recommended?

Name three key parameters that are screened in a semen analysis.

concentration, motility, and morphology

ON TEST - What is the calculation that helps inform of potential treatment options? And what should the number be? (TMC has CMV)

volume X sperm concentration X motility = should be >20-25 Million

Fecundity

Fecundity is defined as the probability of a woman achieving a live birth for any given month

men - causes of infertility - acquired conditions

Acquired conditions: Infections causing testicular swelling (mumps, gonorrhea, or chlamydia) Varicocele-> enlargement of veins in the scrotum Lifestyle Environmental Age-related factors

men - causes of infertility - endocrine (the end for men is THD)

Endocrine: Diabetes Hyperprolactinemia (elevated prolactin) Thyroid

oligospermia

fewer sperm cells

azoospermia (A = absent)

no sperm

fibroids - Submucosa (mucus in the uterus)

Submucosa (push into uterus) l,

fibroids - Intramural (muscle mural)

Intramural (in the muscle)

fibroids - sub serosal (seriously in the cavity)

Sub serosal (intra-cavity - this is the worst)

Most common tests for tubal patency: (HHot for tubes)

Hysterosalpingogram (HSG) Laparoscopy with chromopertubation (dye into tube and watch it) New tesfet: HyCoSy

fertility test - when is FSH done?

day 1-4 menstrual cycle

risk factors for early DOR

Risk factors for early loss of ovarian reserve include: Smoking Family History of premature ovarian failure Previous ovarian surgery Previous chemotherapy

unexplained infertility - what should AMH be?

(AMH >1)

unexplained infertility - FSH and E2 - this is just the normal #s you already know

by "day 3" FSH/E2 (FSH less than <10 w/E2 less than <80)

asthenospermia (a start with motility)

poor motility

most important in sperm test

TMC >20-25 M (Total Motile Sperm Count (TMC) is a calculation of: Ejaculation Volume x Sperm Concentration x Motility)