Common diagnosis Flashcards
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
“Normal” couples have a fecundity approaching what percentage?
A. 5%
B. 20%***
C. 50%
D. 75%
Etiology of Primary Infertility
(primarily OUTDAE)
- Ovulatory Disorders
- Uterine Factor
- Tubal Factor
- Diminished Ovarian Reserve
- Age
- Endometriosis
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)
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)
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
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
Nonobstructive Azoospermia:
No sperm is being produced due to a structural or functional defect in the testicle.
Causes:
Hormonal
Genetic
Testicular
Nonobstructive Azoospermia: - options?
Possible to try surgical procedure to retrieve sperm—low chance for success
Medication may help..
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
female factors
(OUTDAE)
ovulation disorders, uterine factor, tubal factor, diminished ovarian reserve (DOR), age, endomentrosis
ovulation disorders
(PHHHL has ovulation disorders)
PCOS, Hypogonadotropic Hypogonadism (“hypohypo”), hypothyroidism, hyperprolactemia, luteal phase deficiency
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.
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
adenomysosis
(aden grows)
Endometrial tissue grows into the uterine muscle.
mullerian anomalies - is it congenital?
Congenital disorder of the female reproductive tract.
Uterine Anomalies:
Fibroids (muscle tumor)/myoma
Polyps
Adenomyosis
Mullerian anomalies
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)
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)
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
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
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)
Diminished Ovarian Reserve (DOR)
DOR refers to accelerated ovarian aging resulting in reduced fertility
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 (“hypohypo”) - 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 calculationthat 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)
