EXAM #1: INFERTILITY & PCOS

Question 1

What is the definition of infertility?

Answer 1

Couple that is having regular unprotected sex that has not conceived within 12 months

Question 2

When does the timeframe for infertility change to six months instead of 12 months?

Answer 2

If the woman is over 35 y/o

Question 3

Aside from a woman being older than 35 y/o, generally why would you start a fertility evaluation sooner?

Answer 3

If there is a KNOWN fertility risk factors

Question 4

What are two infertility risk factors in females?

Answer 4

1) Irregular cycles

2) Endometriosis

Question 5

Define fecundability.

Answer 5

Ability to conceive within a given reproductive cycle

Question 6

What are the most common female causes of infertility?

Answer 6

1) Ovulatory dysfunction
2) Endometriosis
3) Tubal damage
4) Cervical factor

Question 7

What are the key components of an infertility HPI for females?

Answer 7

1) Menstrual cycle characteristics
2) Frequency and timing of intercourse
3) Length of infertility (“how long have you been trying?”)
4) Lubrication
5) Dysparenuia

Question 8

What are the key components of an infertility OB/GYN- History for females?

Answer 8

1) Previous pregnancies including miscarriages
2) STIs
3) Pap results
4) Past contraception

Question 9

What are the key components of an infertility Medical History for females?

Answer 9

1) DM
2) Thyroid issues
3) Hirsutism
4) Galactorrhea
5) Chemotherapy/radiation
6) Weight changes

Question 10

What are the key components of an infertility Surgical History for females?

Answer 10

1) Appendectomy (ruptured as a child leads to tubal damage)
2) D/C (Asherman’s Syndrome)
3) LEEP (Cervical stenosis)
4) Laproscopy for Endometriosis (tubal damage)

Question 11

What are the key components of an infertility history for males?

Answer 11

1) Previous occupation
2) Testicular injury
3) Cryptorchidism
4) Hernia repair surgery
5) Anabolic steroid use
6) Alcohol/tobacco
7) Occuption (regarding potential heat to the groin)

Question 12

What are the key components of an infertility physical exam for females?

Answer 12

1) Weight/BMI
2) Skin
- Acne
- Hirsutism
- Acanthosis nigricans
3) HEENT:
- Visual fields (pituitary adenoma)
- Goiter
4) Breasts for galactorrhea
5) Pelvic exam

Question 13

What are the key components of an infertility physical exam for males?

Answer 13

1) Check for signs of undermasculinization
- Gynecomastia
- Small testes
2) Check for hernia
3) Varicosities

Question 14

What lab evaluation is crucial in to order for the male partner in an infertile couple?

Answer 14

Semen analysis with morphology

Question 15

How should you initially evaluate the female in an infertile couple?

Answer 15

1) UA, Vaginal culture, Pap-smear, wet-mount
2) CBC, TSH, T4, T3, FSH (day 3), Prolactin, DHEA-S, total testosterone
3) Basal Body Temperature
4) Day 21 serum progesterone
5) Progesterone challenge test

Question 16

If the LH/FSH are abnormal, what should you do?

Answer 16

Fasting insulin: glucose ratio

Question 17

What is the ideal insulin:glucose ratio?

Answer 17

Greater than 3

I.e. there should be at least 3x as much glucose as insulin

Question 18

After lab testing, what should be done in the evaluation of an infertile couple?

Answer 18

Confirm tubal patency with either:

• HSG (Hysterosalpinoggram)
• Sonohystogram (US with fluid dye)

Question 19

How should you initially manage the infertile couple?

Answer 19

1) Discuss timing and frequency of intercourse
2) Discuss social and occuptional hazards
3) OTC pre-natal vitamin
4) Discuss the “infertility path” and the fee-for-service nature

Question 20

What is the proper timing of intercourse to get pregnant?

Answer 20

Sex on days 10-20 of the menstrual cycle, every other day

Question 21

What drugs are used to treat PCOS?

Answer 21

Clomiphene

Letrazole

Question 22

What drug is used to treat a luteal phase defect i.e. the lutal phase of the menstrual cycle is shortened?

Answer 22

Progesterone

Question 23

What drugs are used to treat anovulation?

Answer 23

Clomiphene
Letrazole

*Same as PCOS

Question 24

What is the expected trend of a B-HCG in a pregnant woman?

Answer 24

Double every 48 hours

Question 25

What are the B-HCG discriminatory markers for TVUS and abdominal US?

Answer 25

• 1500 for TVUS

- 6500 for abdominal US

Question 26

What is PCOS?

Answer 26

Polycystic Ovarian Syndrome

Question 27

What is the clinical presentation of PCOS?

Answer 27

Patients must have two of the following for the diagnosis of PCOS:

1) Hyderandrogenism (hirsutism)
2) Oligomenorrhea or amenorrhea
3) Polycysitc ovaries on US

Question 28

Aside for the three hallmark clinical manfiestations associated with PCOS, what are the other conditions associated with PCOS?

Answer 28

1) Obesity
2) T2DM
3) OSA
4) Dyslipidemia
5) Thyroiditis
6) Mood disorders

Infertility

Question 29

What is the general treatment approach to PCOS?

Answer 29

1) Rule out alternative causes
- Hypothyroid
- Hyperprolactinemia
- Androgen-secreting tumor
- Adult onset congenital adrenal hyperplasia
- Cushing Syndrome
- Pregnancy

Question 30

What US finding is pathognomonic for PCOS?

Answer 30

“String of pearls”

Question 31

What LH:FSH ratio is seen in PCOS?

Answer 31

Greater than 2

Question 32

What is the role of insulin in PCOS?

Answer 32

• Insulin increases ovarian androgen production
• Increased androgens inhibit hepatic production of sex-hormone binding globulin (SHBG)
• Lack of SHBG leads to increased circulating free androgens
• Free androgens alter follicular development

Question 33

How is PCOS treated?

Answer 33

1) Diet and exercise
2) Oral contraceptive pills (if NOT desiring pregnancy)
- Norgestimate
- Desogestrel
3) Spironolactone (aldosterone and androgen antagonist) with contraceptive pill
4) Metformin ONLY IF GLUCOSE INTOLERANCE

Question 34

Specifically how is PCOS infertility treated?

Answer 34

1) Progesterone challenge
- If NO OVULATION– Clomiphene or Letrozole
2) Check serum progesterone on day 21
- Increase dose if no ovulation

Question 35

What are the lifelong complications of PCOS?

Answer 35

1) Cardiovascular Disease
2) T2DM
3) Endometrial cancer