EXAM #1: INFERTILITY & PCOS Flashcards
What is the definition of infertility?
Couple that is having regular unprotected sex that has not conceived within 12 months
When does the timeframe for infertility change to six months instead of 12 months?
If the woman is over 35 y/o
Aside from a woman being older than 35 y/o, generally why would you start a fertility evaluation sooner?
If there is a KNOWN fertility risk factors
What are two infertility risk factors in females?
1) Irregular cycles
2) Endometriosis
Define fecundability.
Ability to conceive within a given reproductive cycle
What are the most common female causes of infertility?
1) Ovulatory dysfunction
2) Endometriosis
3) Tubal damage
4) Cervical factor
What are the key components of an infertility HPI for females?
1) Menstrual cycle characteristics
2) Frequency and timing of intercourse
3) Length of infertility (“how long have you been trying?”)
4) Lubrication
5) Dysparenuia
What are the key components of an infertility OB/GYN- History for females?
1) Previous pregnancies including miscarriages
2) STIs
3) Pap results
4) Past contraception
What are the key components of an infertility Medical History for females?
1) DM
2) Thyroid issues
3) Hirsutism
4) Galactorrhea
5) Chemotherapy/radiation
6) Weight changes
What are the key components of an infertility Surgical History for females?
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)
What are the key components of an infertility history for males?
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)
What are the key components of an infertility physical exam for females?
1) Weight/BMI
2) Skin
- Acne
- Hirsutism
- Acanthosis nigricans
3) HEENT:
- Visual fields (pituitary adenoma)
- Goiter
4) Breasts for galactorrhea
5) Pelvic exam
What are the key components of an infertility physical exam for males?
1) Check for signs of undermasculinization
- Gynecomastia
- Small testes
2) Check for hernia
3) Varicosities
What lab evaluation is crucial in to order for the male partner in an infertile couple?
Semen analysis with morphology
How should you initially evaluate the female in an infertile couple?
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
If the LH/FSH are abnormal, what should you do?
Fasting insulin: glucose ratio
What is the ideal insulin:glucose ratio?
Greater than 3
I.e. there should be at least 3x as much glucose as insulin
After lab testing, what should be done in the evaluation of an infertile couple?
Confirm tubal patency with either:
- HSG (Hysterosalpinoggram)
- Sonohystogram (US with fluid dye)
How should you initially manage the infertile couple?
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
What is the proper timing of intercourse to get pregnant?
Sex on days 10-20 of the menstrual cycle, every other day
What drugs are used to treat PCOS?
Clomiphene
Letrazole
What drug is used to treat a luteal phase defect i.e. the lutal phase of the menstrual cycle is shortened?
Progesterone
What drugs are used to treat anovulation?
Clomiphene
Letrazole
*Same as PCOS
What is the expected trend of a B-HCG in a pregnant woman?
Double every 48 hours
What are the B-HCG discriminatory markers for TVUS and abdominal US?
- 1500 for TVUS
- 6500 for abdominal US
What is PCOS?
Polycystic Ovarian Syndrome
What is the clinical presentation of PCOS?
Patients must have two of the following for the diagnosis of PCOS:
1) Hyderandrogenism (hirsutism)
2) Oligomenorrhea or amenorrhea
3) Polycysitc ovaries on US
Aside for the three hallmark clinical manfiestations associated with PCOS, what are the other conditions associated with PCOS?
1) Obesity
2) T2DM
3) OSA
4) Dyslipidemia
5) Thyroiditis
6) Mood disorders
Infertility
What is the general treatment approach to PCOS?
1) Rule out alternative causes
- Hypothyroid
- Hyperprolactinemia
- Androgen-secreting tumor
- Adult onset congenital adrenal hyperplasia
- Cushing Syndrome
- Pregnancy
What US finding is pathognomonic for PCOS?
“String of pearls”
What LH:FSH ratio is seen in PCOS?
Greater than 2
What is the role of insulin in PCOS?
- 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
How is PCOS treated?
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
Specifically how is PCOS infertility treated?
1) Progesterone challenge
- If NO OVULATION– Clomiphene or Letrozole
2) Check serum progesterone on day 21
- Increase dose if no ovulation
What are the lifelong complications of PCOS?
1) Cardiovascular Disease
2) T2DM
3) Endometrial cancer
