INFERTILITY Flashcards
STANDARD INFERTILITY EVALUATION (ASRM, 2006)
Semen Analysis
Assessment of Ovulation
Hysterosalphingogram - make sure patient is not pregnant; avoid exposure of eggs to radiation
If indicated:
Ovarian reserve
Laparoscopy
Always dapat may pake sa male partner
Ask if:
fathered any childen before?
erectile dysfunction?
DM?
Pertinent data na need sa Past Medical History
Give 5
PCOS (anovulation) Endometriosis (tubal obstruction) PID (tubal obstruction) STD Appendectomy (previous surgeries) --> Adhesions
residence of the couple, do they live together?
less time to have sex if magkalayo
If anovulation ang problem why cannot conceive, what conditions would you think of and what workups?
PCOS - high LH, FSH ratio leading to anovulatory cycles
Hypothyroidism - thyrotropin releasing hormone –> stimulation of prolactin
Hyperprolactinemia -
High prolactin levels inhibit secretion of FSH, which is the hormone that triggers ovulation. So, if your prolactin levels are high, your ovulation may be suppressed.
Serum Prolactin level normal values
Nonpregnant women: less than 25 ng/mL (25 µg/L)
Pregnant women: 80 to 400 ng/mL (80 to 400 µg/L)
TSH, T3, T4 levels normal values
TSH normal values are 4.5 to 5.0 mU/L.
Serum TSH normal – No further testing performed
- Serum TSH high – Free T4 added to determine the degree of hypothyroidism
- Serum TSH low – Free T4 and T3 added to determine the degree of hyperthyroidism
FT4 is between 10-28 pmol/l.
dx and
treatment for PROLACTINOMA
dx: Serum PRL (280)
Cranial MRI scan - if there is macro or microadenoma (10mm cut off)
Prescription Bromocriptine (Parlodel) 2.5mg/tablet Sig: Take 1 tablet orally 2 weeks? Reassess If symptoms improve - continue for 4 weeks May be given for as long as 6 months
Medroxyprogesterone acetate (Provera) 10mg/tab (10 TABLETS)
Sig. Take 1 tablet orally at night
Wait for bleeding as soon as 3 days up to 7 days after last tab
After she bleeds - count that as day 1 - tell her to take it again day 16-25 (continue for 6 cycles)
After 1 month can check again with prolactin levels because ovulation may revert back to normal
Follow up
Reassess Serum Prolactin after 6 months
If responsive to MPA, may continue treating Prolactinoma
enlargement of thyroid gland grading
GRADING (0, Ia, Ib, II, III)
GRADING (0, Ia, Ib, II, III)
0 - no goiter
Ia - Goiter detectable only by palpation & not visible when neck is fully extended
Ib - Goiter visible with neck extension
II - Goiter visible even if neck not extended, as in kahit kausap mo siya nakikita mo
III - very large goiter recognized at a distance, nasa kabilang classroom kita mo
progesterone withdrawal test
(+) Bleed: amenorrhea dt anovulation (PCOS, hyperthyroidism, hyperprolactinemia) (-) Bleed: prob with estrogen secretion Give estrogen and prog (+) bleed: HPO axis defect (-) bleed: uterine defect
Only diagnostic workup for the male
what do you evaluate doon?
SEMEN ANALYSIS - eliminate male factor first since it is inexpensive and easier to do
Abstinence for 2-3 days for adequate spcimen
perform act of coitus (catholics) not masturbation
POST COITAL TEST: specimen collected at endocervical area after the couple have sex
- morphology
- motility
- liquefaction time - some ejaculate are too thick loaded with mucin sperm cannot easily reach ovum
after this work up the woman
How do you evaluate Ovulation?
- Ultrasound of Follicles - may suffice to check for ovulation
Evaluate growth of follices at day 12
dominant follicle - up to 20 mm or 2 cm
mature follicle - 18 mm
Day 16, the dominant follicle should’ve ruptured and shrink = OVULATION
- Urinary LH - easier to do; document LH surge to predict ovulation (parang pregnancy test kit)
Can advise couple to have sex when urinary LH is positive
problems in the fallopian tube like _________ can cause infertility
infection –> ascend and affect mucosa of the fallopian tube –> ADHESION (answer)
fallopian tube function in fertility
tubes wont be able to pick up the extruded oocyte and the sperm cannot reach the fallopian tube
tubes SUCTION the dominant follicle to the ampulla where it waits for fertilization
past history of ________
ruptured appendicitis
previous appendectomy
How would you evaluate patency of Fallopian Tubes
2 procedures
When is it done?
Precaution
HYSTEROSALPHINGOGRAPHY - outpatient procedure, anesthesia no need for anesthesia; XRAY method dye will be injected into the genital tract
Normal or Patent tubes - spillage of dye seen in xray
Abnormal: dilatation without spillage
Day 8-10 - we have to wait for mens to avoid irradiation and possible pregnancy
Make sure patient is not pregnant
Prophylactic Antibiotic for Hysterosalphingography
Doxycycline 100 mg BID, for 3 days, starting 1 day before the procedure
How would you evaluate patency of Fallopian Tubes
that is both diagnostic and therapeutic
advantage?
LAPAROSCOPY with CHROMOPERTUBATION
Methylene blue or sterilized milk
Both diagnostic and therapeutic
Possible intraoperative adhesion in ileocecal area
Endometriosis (fixation, retroverted uterus)
ADHESIOLYSIS - can be performed immediately during the procedure
CYSTECTOMY - if there are cysts
Remove implants if endometriosis present -
SURGICAL TREATMENT FOR INFERTILITY
Laparoscopy with Adhesiolysis
Salpingostomy - for distal obstruction
Ovulatory agents for PCOS
Note: Do progesterone withdrawal test muna
MPA - amenorrheic patients
Clomiphene Citrate - not amenorrheic; Clomifene appears to stumulate the release of gonadotropins, follicle-stimulating hormone (FSH), and leuteinizing hormone (LH), which leads to the development and maturation of ovarian follicle, ovulation, and subsequent development and function of the coprus luteum, thus resulting in pregnancy.
Letrozole (more effective) -
Letrozole is a non-steroidal type II aromatase inhibitor. prevents the conversion of androgens to estrogen. This action leads to elevation in LH (off label use but more effective) Letrozole (aromatase inhibitory) let LH win!!!!!!!
MOA of letrozole
Letrozole (more effective) -
Letrozole is a non-steroidal type II aromatase inhibitor. prevents the conversion of androgens to estrogen. This action leads to elevation in LH (off label use but more effective) Letrozole (aromatase inhibitory) let LH win!!!!!!!
MOA of clomiphene citrate (clomid) (clomin) (clostil)
instructions to patient
Clomiphene Citrate - not amenorrheic; Clomifene appears to stumulate the release of gonadotropins, follicle-stimulating hormone (FSH), and leuteinizing hormone (LH), which leads to the development and maturation of ovarian follicle, ovulation, and subsequent development and function of the coprus luteum, thus resulting in pregnancy.
Start 50 mg dose given as early as day 2 to day 6 of menstrual cycle (early proliferative phase)
check utz for evidences of ovulation
collapsed and presence of fluid in the cul de sac
presence of corpus luteum
Goal: follicle formation
Schedule intercourse within 24 hours
diagnosis if patient is nulligravid
PRIMARY INFERTILITY
what conditions would you think of when you are considering infertility?
HI YIELD NEVER FORGET kasi ito magguide sa history pe mo
Ovulatory causes - pcos, hyperthyroid, prolactinoma
tubal causes - PID, endometriosis, adhesions from previous surgeries
