Female Infertility 2 Flashcards
Describe the differential diagnosis of infertility.
1
Q
What are the common disorders in the differential diagnosis for infertility?
A
- Male factor
- Anatomic disorders of the female reproductive tract
- Anovulation
- Decreased ovarian reserve
2
Q
What are the common male factors that lead to infertility?
A
- Usually idiopathic (40-50%)
- Primary gonadal disorders (30-40%)
- Disorders of sperm transport (10-20%)
- Hypothalamic-pituitary disorders (1-2%)
3
Q
What are some common anovulatory causes of infertility?
A
-
More common:
- polycystic ovarian syndrome
- hypothalamic amenorrhea
-
Less common:
- hyperprolactinemia
- thyroid disease
- premature ovarian failure
4
Q
What are some anatomic abnormalities of the female reproductive tract that can lead to infertility?
A
-
Abnormalities of the uterine cavity
-
congenital
- __mullerian duct abnormalities
-
acquired
- __fibroids, polyps, Asherman’s syndrome
-
congenital
-
Abnormalities of the fallopian tubes
- usually related to prior ascending infection or pelvic surgery
5
Q
What effect does age have on infertility?
A
- No significant effect on the uterus or endometrial development or function
- No effect on the egg itself in terms of live birth per transfer rate
-
Decreased ovarian reserve
- 6-7 million oogonia by 16-20 week gestation and 1-2 million at birth
- 300,000 to 500,000 at puberty, 400-500 at reproductive age
- By age 40, size of the follicular pool declines to ~25,000
- At menopause, <1000 follicles remain
6
Q
Polycystic ovary syndrome
A
- Most common endocrinopathy of women
- Perimenarchal onset
- Hyperandrogenemia
- Insulin resistance
- Frequently associated with obesity
7
Q
Hypothalamic amenorrhea
A
-
Usually a functional disorder:
- Excessive exercise
- Inadequate nutrition
- Stress
- Common pathway is disruption of pulsatile GnRH secretion from the hypothalamus
8
Q
What are some less common problems that lead to infertility?
A
- Cervical abnormalities
- Endometriosis
- Sexual dysfunction
9
Q
What are some cervical abnormalities that can lead to infertility?
A
- Chronic cervicitis or cervical stenosis
- conization or other treatments for cervical disease
- impairs sperm-mucus interaction
- usually identified by speculum examination
10
Q
Endometriosis
A
- Benign disease, defined by presence of endometrial glands and stroma outside of the uterus
- ectopic tissue usually located in the pelvis but can appear anywhere in the body
- Associated with pelvic pain and infertility
- Possible pathogenic mechanism (no generally accepted theory)
- retrograde menstruation and implantation
- coelomic metaplasia
- direct transplantation
- vascular dissemination
11
Q
How does endometriosis cause infertility?
A
-
20-40% of infertile women have the disease
-
distorted adenexal anatomy
- inhibits or prevents ovum capture after ovulation
-
excess production of:
- prostaglandins
- metalloproteinases
- cytokines
- chemokines
- results in chronic inflammation
- impairs ovarian, tubal, or endometrial function
- disorders of folliculogenesis, fertilization, or implantation
-
distorted adenexal anatomy
12
Q
How is the diagnosis of unexplained infertility derived?
A
-
Diagnosis of exclusion
-
implies the following:
- normal semen quality
- normal ovulatory function
- normal uterine cavity
- bilateral tubal patency
-
implies the following:
- Incidence from 10-30% among infertile populations
-
2 potential explanations for unexplained infertility
- poor oocyte quality
- other specific abnormalities that cannot be identified with existing tests:
- sperm function
- fertilization
- implantation
- embryo development