Infertility Flashcards
DEFINITION
Failure of a couple to conceive after 1
year of regular intercourse without use of contraception
Primary infertility
No prior pregnancies
Secondary infertility
Prior pregnancy regardless of outcome.
Major causes of infertility: ▪ Female factor – 50%
▪ Reproductive aging
▪ Ovulatory dysfunction
• Hypothalamic Pit. Failure (Type 1)
• Hypothalamic Pit. Dysfunction (Type 2)
• Ovarian Faliure (Type 3)
• Hyperprolactinemia
▪ Abnormalities of female reproductive tract.
▪ Peritoneal factors
• Acute salpingitis
N. gonorrhea and C. trachomatis
➢ Intrauterine scarring
Can be caused by curettage D&C
➢ Endometriosis.
➢ Scarring from surgery.
➢ tumors of the uterus and ovary(e.g
:myoma.endometrioma ).
➢ Endometriomas.
Major causes of infertility male
• Abnormal semen quality
• Abnormalities of male reproductive tract
• varicocele
• idiopathic
• bilateral obstruction vascular deference :
Congenital : cystic fibrosis
Ligation during hernia
Gonorrhea
• immunological anti-sperm.
• undescended testis.
• exposure to the radiation chemical smoking , orchitis ( mumps, TB )
• klinfelter’s syndrome 47xxy
• hyperprolactnemia - hypothyroidism
• drugs.
• failure of deposition of sperm:
Severe hypospadius
Impotence
Retrograde ejaculation
Fecundability
probability of
achieving a pregnancy within 1 menstrual cycle (25%)
Fecundity
ability to achieve a live birth within 1 menstrual cycle (6%)
Conception rate (fecundability)
25% conceive within 1 mo.
▪60% conceive within 6 mo.’s
▪75% conceive within 9 mo.’s
▪90% conceive within 18 mo.’s
Successful conception requires a specific series of events:
- Ovulation of competent oocyte.
- Production of competent sperm.
- Juxtaposition of sperm and oocyte in a patent reproductive tract.
- Fertilization.
- Generation of a viable embryo.
- Transport of the embryo to the uterine cavity.
- Implantation of the embryo into the endometrium.
• Hypothalamic Pit. Failure(Type 1)
Causes
• Anorexia nervosa
• Exercise –related
• Post pill amenorrhea
• Pitutry infarction ( Sheehans syndrome )
• Kalman’s syndrome
• Hypothyroidism
• Idiopathic
• Hypothalamic Pit. Dysfunction (Type 2).
Causes
Most common
PCOS ——-
• Affects women with irregular menses and an inability to maintain
normal BMI
• Usually includes elevated levels of serum androgens, insulin resistance
and chronic anovulation
• FSH/LH ratio
• Androgen level
• IR
• Health problem (DM,CVD,MS–)
• Treatment
Ovarian Faliure (Type 3)
Causes
(( hypergonadotrophic hypogonadism ))
• Premature and age related ovarian failure
• Resistant ovarian syndrome
• Turner syndrome
• ———- FSH , LH – HIGH
• E-low
What drugs you will ask in the male history infertility ?
Furantoins, CCB
male infertility evaluation
• Male (Urologist referral)
▪ Evidence of androgen deficiency
▪ Structural defects (e.g. varicocele,
hernia,deformity)
• Semen analysis :
▪ Following 2-4 day period of abstinence
▪ Repeated x1 for accuracy
▪ Parameter Lower reference limit
Volume 1.5 ml
pH 7.2
Concentration :15 million/ml
Total sperm number 39 million/ejaculate Total motility: (PR+NP) :40% or PR: 32%
Vitality 58% live spermatozoa
Normal forms 4% (strict criteria). Motility: progressive: rapid (a)+ slow (b) A and b Not used in WHO
• Endocrine evaluation
▪ Indication: Oligospermia (< 10million/mL) or sexual dysfunction (decreased libido, impotence)
➢ FSH, LH, testosterone, prolactin
▪Genetic evaluation
▪ Indication: Azoospermia (no sperm)
➢ CFTR mutation
➢ Karyotype (Klinefelter’s, Y chromosome deletion)
• Testicular biopsy
▪ Indication: Nonobstructive azoospermia
▪Palpable vasa
▪ Normal testis volume
▪Normal FSH/LH
• Urologic evaluation:
▪ Physical Exam
▪ Varicocele
▪Congenital absence of vas deferens
(CAVD)
➢ Transrectal ultrasound
➢ Vasography, Seminal vesiculography
➢ Epididymal sperm aspiration (PESA or MESA)
FEMALE FACTOR: EVALUATION
Reproductive aging
▪ Indications:
• > 35 years of age
• 1 st degree relative with early menopause
• Previous ovarian insult (surgery, chemotherapy, radiation) ☢️
• Smoking 🚬
• Poor response to ovarian stimulation • Unexplained infertility
• Candidate for IVF
Female:
▪ Height, weight , BMI
▪ Pelvic exam
▪ Masses
▪ Tenderness (Adnexa, Cul-de-sac) ▪ Structural abnormalities (Vagina, Cervix, or Uterus)
• Ovulation:
- Basal body temp – rise for > 10 days indicates ovulation
- Ovulation predictor kit – detects LH surge in urine
••Further evaluation:
- Endocrine testing (TSH, prolactin, FSH, LH, Estradiol, DHEA-S)
- Mid-luteal phase progesterone level - level > 3 ng/mL provides (( ovulation ))
- Endometrial biopsy /Not routinely performed
- Ultrasound /TVS ( Follicullometry )
(( peroid - uterus , ovary , endometrium ))
(( ovulation - 13, 14 to see mature follicle ))
• Reproductive aging:
▪Cycle day 3 serum FSH and estradiol.
▪Abnormal (“diminished ovarian reserve”)
▪FSH > 10 IU/L
▪Estradiol > 75-80 pg/mL
▪ Clomiphene citrate challenge test (CCCT)
▪Cycle day 10 serum FSH
▪Serum anti-mullerian hormone (AMH)
•• Reproductive tract
▪ Initial evaluation:
- Hysterosalpingogram (HSG)
(( Detect uterine anomalies (septate or bicornuate uterus, uterine
adhesions, uterine leiomyoma ))
(( Detect patency of fallopian tubes (occlusion, hydrosalpinx, salpingitis))
• Complication (Allergy,perforation , infection )
- Ultrasound – alternative to HSG to evaluate uterus
•• Further evaluation:
▪Saline-infusion sonography (SIS)
▪Hysteroscopy
▪Laparoscopic chromotubation
•• Peritoneal factors
▪Laparoscopy
➢ Endometriosis
➢ Pelvic/adnexal adhesions
