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Repro Week 3 > ICL 15.4: Female and Male Infertility > Flashcards

ICL 15.4: Female and Male Infertility Flashcards

1
Q

how many eggs do we have?

A

6-7 million at 16-20 weeks gestation

500,000-2 million eggs at birth

300,000 to 500,000 at puberty….

over the reproductive years, 400-500 oocytes are ovulated

at menopause, only a few hundred remain (at about 1000 eggs, your body starts menopause)

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2
Q

where does fertilization occur?

A

ampulla of the fallopian tube

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3
Q

what is the location of action and hormone released by the hypothalamus?

A

location of action: arcuate nucleus

hormone: GnRH

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4
Q

what is the location of action and hormone released by the anterior pituitary?

A

releases GSH and LH

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5
Q

what is the location of action and hormone released by the ovary?

A

acts on the follicle and corpus luteum

releases estradiol, progesterone, inhibin, MIS, activin

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6
Q

what is the location of action and function of the uterus?

A

acts on the endometrium

proliferative, secretory and meses!

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7
Q

what does FSH act on and what does it do?

A

FSH acts on the granuloma ells to produce estradiol

this happens by stimulating aromatase

they’re suppressed by rising estradiol and by inhibin

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8
Q

what does LH act on and what does it do?

A

LH acts on theca cells that then produce androgens

these androgens go to the granuloma cells and via aromatase, you make estrogen!

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9
Q

what does the corpus luteum produce?

A

progesterone and estrogen

if there’s no fertilization, corpus luteum degrades so it’s usually around for only 14 days

if you get pregnancy, hCG rescues the CL to continue making progesterone and estrogen till the placenta can take over

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10
Q

what phase of meiosis is the egg in throughout the menstrual cycle?

A

the egg is in arrested in prophase of meiosis I until it becomes the dominant follicle

then after/at ovulation, the oocyte completes metaphase of meiosis II and is arrested here until fertilization

at fertilization, the secondary oocyte completes meiosis II to form a mature oocyte (23,1N) and a second polar body

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11
Q

how successful is conception?

A

20-25% on a monthly basis

after 3 months, it’s 50%

after 6 months, 75% conceive

after 12 moths, 85% are able to conceive

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12
Q

which gynecologist disorders increase with age?

A
  1. fibroids
  2. tubal disease
  3. endometriosis
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13
Q

why does age effect pregnancy success?

A

as egg quality decrease, it’s hard to undergo proper meiosis so there’s higher rates of spontaneous abortions in the 1st trimester due to embryo aniploidy = to much genetic material like Turners, Downs, etc.

unbalanced embryos aren’t good so the maternal body is smart and it miscarries because it realizes something is wrong

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14
Q

what is infertility?

A

failure to conceive a successful pregnancy after 12 months or more of regular unprotected intercourse or exposure to sperm

secondary infertility is when they’ve had a kid before but now they want another one and they are struggling

effects 10-15% of couples

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15
Q

what are the risk actors for infertility?

A
  1. anoculation
  2. ectopic pregnancy
  3. pelvic infections
  4. endometriosis
  5. chemo
  6. male infertility

if there’s any of these present you should start treatment immediately!!

if they dont have risk factors, treat when:
1. there has been 12 months without conception and the woman is under 35

  1. there has been 6 months without conception in a woman over 35
  2. give immediate care for a woman over 40
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16
Q

what are the causes of infertility?

A
  1. male problems (35%)

approximately 5-10% of men evaluated for infertility are azoospermic aka no sperm!

  1. tubal and pelvic pathology (35%)
  2. ovulatory dysfunction (15%)
  3. unexplained (15%)
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17
Q

what should you screen when looking at infertility?

A

TUSHY

Tubes
Uterus
Sperm
Hormones
Your genetic profile
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18
Q

what common causes of infertility are associated with the ovary?

A
  1. PCOS
  2. hyperprolactinemia
  3. hypothalamic/pituitary dysfunction
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19
Q

what common causes of infertility are associated with the tubes?

A
  1. inflammatory disease

2. ectopic pregnancy

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20
Q

what common causes of infertility are associated with the uterus?

A
  1. developmental anomalies
  2. polyps/fibroids
  3. scar tissue
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21
Q

how do you diagnose infertility?

A
  1. ovulatory dysfunction: timed serum proesterone, ovulation predictor kits, US
  2. ovarian reserve/reproductive aging: AMH, FSH/E2, AFC
  3. tubal occlusive disease: X-ray, infusion hysterosonography, HyCoSy
  4. uterine abnormalities: x-ray HSG, US
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22
Q

what is a normal menstraul cycle?

A

21-25 days

variation is common and normal

if someone tells you cycles are predictable and premenstrual symptoms are present than you can be 90-95% sure they’re ovulating!

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23
Q

what is a normal menstraul cycle?

A

21-25 days

variation is common and normal

if someone tells you cycles are predictable and premenstrual symptoms are present than you can be 90-95% sure they’re ovulating!

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24
Q

how do ovulation predictor kits work?

A

they detect mid cycle urine LH surge so they will be positive 24 hours before ovulation!

false positive only 7%, false negative 25% of the time

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25
Q

what are the common causes of ovulatory dysfunction?

A
  1. PCOS
  2. obesity
  3. strenuous exerise
  4. thyroid dysfunction
  5. hyperprolactinemia

could me premature ovarian insufficiency aka premature menopause

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26
Q

what do high FSH levels indicate when doing ovarian reserve testing?

A

2-5 day FSH levels

if FSH is super high is a poor prognosis – if ovaries aren’t working and aren’t producing enough estrogen, then the positive feedback to the pituitary which will make a ton of FSH in response

on the flip side, super high estrogen can suppress FSH via negative feedback and that can be bad too

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27
Q

what is ovarian reserve testing?

A

indirect measure of remaining eggs

it looks at the ability of ovaries to produce eggs and respond to treatment

doesn’t tell you about natural fertility, it just tells you about fertility treatment because low egg counts can still be functional! egg count doesn’t predict natural fertility but it does predict window of reproductive opportunity because you know you dont have a lot of eggs left and you might need to figure things out with more urgency

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28
Q

what do you give for infertility with PCOS patients? how do they work?

A
  1. clomiphene citrate

selective estrogen receptor modulator (SERM) so it’s an estrogen agonist and antagonists

it binds to hypothalamus to block estrogen receptors so that the hypothalamus senses a decrease in estrogen to increase GnRH levels

  1. letrozole

aromatase inhibitor that blocks androgen conversion to estrogens so that the body senses low estrogen and will make more GnRH

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29
Q

what is an X-ray hysterosalpingography?

A

looks at the fallopian tubes through water or lipid soluble contrast media

evaluate proximal occlusions, salpingitis isthmica nodosa, distal occlusion, hydrosalpinx, contrast location

30
Q

what is an X-ray hysterosalpingography?

A

looks at the fallopian tubes through water or lipid soluble contrast media –> high specificity but low sensitivity

evaluate proximal occlusions, salpingitis isthmica nodosa, distal occlusion, hydrosalpinx, contrast location

however, proximal occlusion is often inaccurate because if there are myometrial contractions it can make it look like a proximal occlusion

31
Q

how do you treat tubal factor?

A
  1. IVF

if tubes are blocked, bypass them with IVF and put the fertilized eggs back in the uterus

  1. tubal surgery
32
Q

what is hydrosalpinx?

A

blocked distal fallopian tubes which causes fluid backup into the uterus creating a toxic environment that makes it hard for embryos to implant

33
Q

what is the most common Mullerian anomaly?

A

uterine septum

resorption usually occurs after urologic development so not necessary to evaluate renal system in patients with septate uterus

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50
Q

what are the immediate causes of male infertility?

A
  1. compormised sperm production
  • concentration of sperm
  • sperm movement
  • shape of sperm cell
  1. compromised sperm transportation through male tract
    - ductal obstruction - obstructive azoospermia; no sperm in the ejaculate but this is a good prognosis – non-obstructive azoospermia is no sperms poor prognosis because there’s in the ehaculate and no ductal obstruction
51
Q

what are the underlying causes of lack of male infertility?

A
  1. endocrinopathies
    ex. hypogonadism due to GnRH deficiency, hypothyroidism, hyperprolactinemia
  2. current or recent acute or chronic illnessess (DM, HTN)
  3. infections
    ex. enterococcus faecalis, chlamydia, gonorrhea syphilis, mycoplasma, ureaplasma

4 . antisperm antibodies

  1. testicular cancer and its treatment
  2. retrograde ejeaculation
  3. prescription or OTC medications
    ex. spironolactone, ibuprofen, antidepressants
  4. respiratory diseases
    ex. Young’s syndrome, cystic fibrosis
  5. environmental or occupational exposure
    ex. lead, pesticides, excessive heat, bisphenol, phthalates, ethylene oxide*
  6. genetic mutations
    ex. CFTR, Y-chromosome micro deletions, Klinefelters syndrome (XXY)
  7. spinal cord injury or testicular trauma
52
Q

what is retrograde ejaculation?

A

rerouting of seminal fluid from the posterior urethra into the bladder

the sperm is unable to go to the urethra via penis and out – instead it is redirected to the bladder

this results in the ejaculate may be dry or extremely little fluid

53
Q

what are the causes of retrograde ejaculation?

A
  1. congenital: malformation of posterior urethra
  2. acquired: post surgical or trauma
  3. neurogenic: spinal cord lesions, sports injury
  4. neuropathies: DM, MS
  5. pharmacological: chlorpromazine
  6. mechanical: mental stenosis, ureterocele
54
Q

how do you treat retrograde ejaculation?

A

sodium bicarbonate

collect urine from patient and sodium bicarbonate helps sperm survive since it neutralizes the pH of the urine

once the sperm is in the bladder, you tell them to urinate and isolate the sperm form the urine and you do intrauterine insemination

55
Q

what is the diagnostic workup for the male partner?

A
  1. complete history
  2. urologic exam
  3. recent semen analysis
  4. hormone analysis
  5. genetics
  6. testicular imaging
56
Q

what do you ask during a history for an infertile male?

A
  1. duration of infertility
  2. timing of puberty – could indicate abnormalities of HPG axis
  3. childhood urologic disorders like cryptorchidism or hypospadieas
  4. family history (could indicate microdeletions
  5. sexual history: timing of coitus, previous fertility, use of spermicidal lubricants
  6. lifestyle choices/social history like smoking and marijuana and alcohol
57
Q

what do you look for during urological examination of infertile male?

A
  1. testicles
  2. epididymis
  3. vas deference
  4. spermatic cord
  5. penis: anatomic abnormalities, hypospadias, strictures, plaques
  6. rectum: for abnormalities of the prostate or seminal vesicles
  7. body habits: physique, stature, obesity
58
Q

why is hypospadias associated with infertility?

A

normally, ejacualate is supposed to projectile onto the cervix

if the urinary meatus is on the underside of the penis, it will project onto the vaginal floor and get no where near the cervix so this lowers the chances of pregnancy

59
Q

what lab values do you want for male infertility?

A

SEMEN ANALYSIS!!!

a RECENT semen analysis performed within previous 3 months and preferably 2 seems analysis performed one month apart with abstinence for 3 days prior

you check for:
1. semen volume (1.5+ is normal)

  1. semen pH (7.2+ is normal)
  2. semen quality –> sperm concentration, sperm motility, sperm morphology

15+ million sperm/mL of semen is normal semen concentration

normal sperm motility needs to be over 40% of sperm, that is considered normal

sperm morphology must be over 4% sperm with normal sperm shape to be considered normal

60
Q

what are the signs of infection in a semen sample?

A

higher number of WABC in the semen is suggestive of infectious or inflammatory processes

less than 4 per HPF is normal

61
Q

how do we look at sperm concentration?

A

microscope that has a grid on it and count how many sperm are there

62
Q

what is normal sperm morphology?

A
  1. oval shaped head with blue nucleus and pink acrosome at the top
  2. intact midpiece that isn’t swollen
  3. uncoiled single tail
63
Q

which hormones do you test for male infertility?

A

FSH, LH, TSH, testosterone and prolactin

64
Q

which genetic testing do you do for male infertility?

A
  1. CFTR

2. AZF deletions on long arm of Y chromosome that is normally responsible for spermatogenesis

65
Q

which imaging studies do you do for male infertility?

A
  1. transracial US
  2. scrotal US
  3. vasography = look at vas deferens through contrast study
66
Q

what constitutes a competent sperm with a high potential for successful fertilization?

A
  1. 23 sets of chromosomes without any significant chromosomal baerrations
  2. free from any significant and lethal gene defects
  3. oval shaped head with an acrosome, a nucleus, mid piece and uncoiled long tail
  4. motility
67
Q

how do you treat male infertility?

A
  1. lifestyle changes: stop recreational drugs or medications
  2. medical treatment for infections and endocrinopathies
  3. surfical treatments: caricocelectomy, vasectomy reversal
  4. modern assisted reproductive technology treatment like IVF and ICSI because a lot of times the studies are totally normal and we dont know why they aren’t able to get pregnant
68
Q

what is intrauterine insemination?

A

IUI is when you get a sperm sample and mix with a solution to remove seminal plasma which is what the cervix does

so now that you only have the motile sperm, you inject directly into uterus

69
Q

what is the IVF process?

A
  1. ovarian stimulation with hormones
  2. egg retrieval
  3. fertilizing the egg on a petri dish
  4. embryo transfer
  5. 2 week wait

it takes 50,000 sperm per egg to do this!!

if the patient doesn’t have that much sperm you aspirate the epididymus and get sperm directly – if you dont get enough that way, you can open the testis and aspirate the sperm from the seminiferous tubules

70
Q

what is intracytoplasmic sperm injection?

A

isolate sperm from testicular tissue biopsy

then you take the sperm and inject them directly into an egg cytoplasm with a needle

so this way if you can’t get enough sperm with other techniques you can use literally one sperm and put it directly into one egg

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