Infertility Flashcards
Define Infertility
- by age
fertility v. fecundibility
Infertility = a couples problem! not just female/male issue but both
Infertility by definition is
- female age < 35 y/o : inability to conceive after 12 months of regular intercourse
- female age > 35 y/o: inability to conceive after 6 months of regular intercourse
Fertility: the ability to conceive offspring
fecundibility: the PROBABILITY of achieving pregnacny in one menstraul cycle
thus, a 40 y/o is FERTILE, but her fecundibility is much less
Female Infertility Factors
uterine
tubal
ovualry
cervical
Tubal Obstructions
- PID: inflammation/scarring
- endometriosis: scar tissue near/around fimbra
Uterine Factors
- fibroids blocking tubal ostia
- uterine congential abnormalities
- asherman’s syndrome = scarring due to increase procedures
Ovulartory Dysfunction
- thyroid issues
- prolactinomas
- hypogonadotropic gonadism
- PCOS
Cervical Factors
- acute cervicitis
- cervical stenosis
Male Infertility Factors
tubual
sperm
coital
gondal
Sperm
- azospermia: no sperm in ejacuate
Hypogonadism
- low amout of sperm production
Tubal
- seminiferous tubule dysfunction: trauma, scarring
Cotial
- impotence: cant get it up
Ovulatory Cycle specifics
length of follicular and luteal phase
length of time egg is viable and sperm?
Follicular phase: variable in length
- “average” is 14 days
- but this can vary depedning on individual
- ovulation: happens 14 days BEFORE period: so count backwards
Luteal phase: set length
- alwasy 14 days
- so 14 days before; the egg should drop
Egg: viable for 12 hours only
Sperm: viable and hangout for about 3 days
ideally: have sex for teh 5 days leading up to the ovulation, & 1 day after
fertilization: occurs within the tube then the early blastocyte travels to uterus to implant
History Questions during Infertility workup
History
menstural history: detailed
- duration of infertiity
- fertilit before? otehr pregnancies, outcomes, partners history,etc. = clues to female or male side
- cycel lenght, freqeuncy, pain
- GYN hx. sti, etc. menses regularity
OB hx.
- sheehan? ashermans
Medical Hx.
- thyroid disease
- prolactinoma
- PCOS
- endometriosis
- Sexual: STDs, GYN procedures
Surgical History
medications
socail hx.
Physical Exam during Infertility workup
PE
- obese? acanthosis nigrans? (PCOS)
- secondary sex. characteristics: breasts, etc.
- Turners syndrome: webbed neck?
- thyroid exam!!!
- Pelvic Exam: CMT (PID), rectal exam (for endmetrosis and uterosacral thickening)
- androgen excess: hirsutism, ance, baldness
Lab Eval for Infertility
ovulary tests
tubal evaluation
ovarian reserve
Labs
Semen analysis
- amount, volume, number, motlity, vitality
Ovulation Documentation
- day 21 progesterone
- LH predictor kits: more sensitive : shows ovulation via increased LH to know which day the LH surge occurs, then can know and time
(after the above tests)
Tubal Evaluation
- HSG: hysterosalpingogram: fluroscopic dye filles uterine cavity and to the tubes see any occlusions in teh pathway
- Laproscopic eval: with chrompertubation (OR)
- Saline infusion sonohysterogram: US
Ovarian Reserve
- day 3 FSH test
- Clomid Challenege Test (stimulated ovulation)
- AMH & antral follicle count (determiend to be functional ovaries: these see how many, not how functional)
Nonpharm Treatemnt for Infertility
Pt Education
Lifestyle Modifications
- quit smoking
- losing weight if over weight, gaining weight if under
- decreas alcohol/caffeine
- healthy diet
- decrease stress
- stop recreational drug use
Pt. Education
- understanding fertile window (when ovulation happens)
- using LH kits, monitoring cervical mucous
- timing sex, frequency of sex: very 3rd day, every other
When to Refer to ART Specialist
Referral can be….
- when they meet criteria for infertility as defined
- GP can do some small workup but if abnormal results = refer to specialist
who to refer immediately
- those age 40+
- women with oligomehorrhea/amehorrhea
- hx. of chemo, radiation, advanced emdometriosis
- knonw tubal disease
- male partener with groin/testicualr surger, mumps, impotence, chemo
ART techniques for Conception
Induced Ovulation
Clophipehen (clomid) = SERM; triggers estrogen “deficiency” signal, increasing FSH and stimulating follicle and therefore eggs
Letrozole (Femara)
- an E2 blocker: triggers FSH similar to SERM, but more eggs impacted
Gonadotropins (FSH/LH)
these have risk of multiples
Fertilization Methods
- intrauterine insemination (directly at level of fundus)
- IVF: invirto fertilization then implanted
Additional ART Options: donors
Donor Egg
- 21-31 y/o
- healthy, 19-29 BMI
- non-smoker
- regualr periods, not using BC
- healthy with ovaries, no drugs, geneic issues
- take injections
Donor Sperm
- 18-39 y/o
- blooe and urine test for STDS, semen analysis
- genetic testin, psych, eval, no durg use
Psychosocial problems with Infertility
preconception stress can increase risk of infertility
stress = can impact willingness to continue treatemnt
affects and relates to pergnancy loss
anxiety/depression, prior loss and longer infertility hx. be aware of!
