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infertility Flashcards

1
Q

definition of infertility

A
  • Inability to conceive after 1 year of unprotected intercourse of reasonable frequency in women < 35yo
  • Inability to conceive after 6 mo of unprotected intercourse of reasonable frequency in women > 35yo
  • > 40yo – more immediate evaluation and treatment is warranted
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2
Q

If a woman has a condition known to cause infertility then more immediate evaluation may be warranted:

A
  • Oligomenorrhea or amenorrhea
  • Known or suspected uterine, tubal or peritoneal disease
  • Stage 3 or 4 endometriosis
  • Known or suspected male infertility
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3
Q

types of infertility

A
  • Primary - No prior pregnancies
  • Secondary - Following at least one prior conception
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4
Q

Pregnancy involves complex sequence of events:

A
  • Ovulation
  • Ovum pickup in fallopian tube
  • Fertilization
  • Transport of fertilized ovum into the uterus
  • Implantation
  • Receptive uterine cavity
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5
Q

etiology of infertility

A
  • Male 25%
  • Ovulatory 27%
  • Tubal/uterine 22%
  • Other 9%
  • Unexplained 17% - If you cant figure out the problem you will start them on the treatment for an ovulatory issue

Both partners need to be evaluated!

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6
Q

obtaining gynecologic hx for infertility

A
  1. Find out what has been done before
  2. Menstruation
    - Frequency, duration, changes, hot flashes, dysmenorrhea
    - Signs of ovulation: Cervical mucus changes, Ovulation tests, Basal body temps
  3. Prior contraceptive use
  4. H/o ovarian cysts, endometriosis, leiomyomas, STDs, PID
  5. H/o abnormal pap smears
    - Conization – can decrease cervical mucus quality and alter cervical anatomy
  6. Prior pregnancy - Indicates ovulation and patent fallopian tube
  7. Pregnancy complications
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7
Q

components of coital history

A
  1. Frequency
  2. Timing
    - Chance of conception increased 5 days preceding ovulation
    - Should have daily intercourse during this period to maximize chances
  3. Dyspareunia
  4. Lubricants
    - Avoid oil based lubricants that can harm sperm
    - Water based lubricants are preferred
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8
Q

medical hx components that could affect infertility

A
  1. Chemotherapy
  2. Radiation
  3. Androgen excess = PCOS
  4. Thyroid disease
  5. Hyperprolactinemia
  6. Medications
  7. BMI: Modest wt reduction in overweight women can normalize menstrual cycles and increase chance of pregnancy
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9
Q

social hx components that affect infertility

A
  1. Lifestyle
  2. Environmental factors
    - Eating habits
    - Toxins
  3. Smoking
    - Lowers fertility in men and women
    - Prevalence of infertility and time to conception longer in women who smoke
  4. Alcohol
  5. Caffeine
  6. Illicit drugs
  7. Ethnicity
    - Important for consideration of pre-conceptional testing
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10
Q

Key Components of Physical Exam

A
  • Weight, BMI
  • Thyroid enlargement and presence of nodules or tenderness
  • Breast secretions
  • Signs of androgen excess
  • Tanner staging of breasts, pubic and axillary hair
  • Vaginal or cervical abnormalities
  • Uterine size, shape, position and mobility
  • Adnexal masses or tenderness
  • Cul-de-sac masses, tenderness or nodularity
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11
Q

6 MCCs of female infertility

A
  1. Ovulatory disorders
  2. Endometriosis
  3. Pelvic adhesions
  4. Tubal blockage or other tubal problems
  5. Uterine or cervical factors
  6. Unexplained
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12
Q

when should genetic testing be considered for infertility

A
  • History of recurrent pregnancy loss
    • 3 or more consecutive losses at ≤ 20 wks gestation or with a fetal wt < 500g
  • Premature ovarian failure (<40yo)
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13
Q

causes of h/o recurrent pregnancy loss

A
  1. Parental chromosomal abnormalities
    - MC in sporadic miscarriages
    — 50% of spontaneous miscarriages are due to aneuploidy - MC is Monosomy X
  2. Antiphospholipid syndrome
  3. Uterine abnormalities
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14
Q

MCC premature ovarian failure

A

Turners

  • Menopause occurring at a younger age
  • Average age of menopause is 51yo
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15
Q

Ovulation can be affected by abnormalities in the ___, ____, or ____

A

hypothalamus, pituitary or ovaries

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16
Q

common causes of ovulatory dysfunction

A
  • Hypothyroidism
  • Hyperprolactinemia
  • Diminished ovarian reserve- someone who is older w/o good eggs
  • PCOS
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17
Q

relationship with age and ovulatory fysfunction

A

Clear inverse relationship between female age and infertility

  • Linked to loss of viable oocytes
  • Risk of genetic abnormalities and mitochondrial deletions in remaining oocytes substantially increases with age - Causes increased rate of miscarriage
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18
Q

excellent predictor of regular ovulation when evaluating ovulatory dysfunction

A

menstrual hx

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19
Q

what is Mittelschmerz

A

midcycle pelvic pain associated with ovulation

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20
Q

what are Moliminal symptoms

A

breast tenderness, acne, food cravings, mood changes
during ovulation

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21
Q

diagnostics for ovulation dysfunction

A
  1. Labs - TSH, FT4, Prolactin, progesterone, FSH, AMH
  2. Weight - Anorexia and bulimia can cause hypothalamic changes
    - Affects GnRH
    - Obesity may indicate PCOS
  3. Basal Body Temperature
    - Women check morning oral temperature and graphically charts
  4. sonography
  5. ovulation predictor kits
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22
Q

how does basal body temp help indicate ovulation or staging?

A
  • Oral temperatures 97-98°F during follicular phase
  • Postovulatory rise in progesterone levels increase basal temperature by 0.4-0.8°F
  • This rise in temperature is strongly predictive of ovulation
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23
Q

pros and cons of basal body temp for diagnostic testing

A
  • Benefits: Inexpensive, easy
  • Limitations: Insensitive in many women
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24
Q

how does sonography work for diagnostic testing?

A
  • Serial exams can demonstrate maturation of an antral follicle and its collapse during ovulation
  • Count less than 5-7 can indicate diminished ovarian reserve
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25
Q

pros and cons of sonography

A

Benefits: Useful in diagnosis of PCOS
Limitations: Time consuming, Expensive

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26
Q

how do Ovulation Predictor Kits work?

A
  • Tests concentration of urinary LH
  • Woman should begin testing 2-3 days before predicted LH surge and continue daily
  • Test with concentrated first morning void
  • Ovulation will occur the day following the urinary LH peak
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27
Q

pros and cons of ovulation predictor kits

A
  • Benefits: in some studies shown to have sensitivity of 100%
  • Limitations: Expensive
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28
Q

In classic 28 day cycle, check serum ____ on day 21
Can also be checked 7 days following ovulation

A

progesterone

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29
Q

serum progesterone levels during ovulation cycle

A
  1. Follicular phase < 2ng/mL
  2. Indicative of Ovulation >3 ng/mL
    - Progesterone is being produced by the corpus luteum
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30
Q

pros and cons of serum progesterone levels as diagnostics

A
  • Benefits: Easy to do
  • Limitations: Progesterone secreted in pulses and a single measurement may not be indicative of overall production
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30
Q

Sensitive predictor of ovarian reserve

A

serum FSH
Typically performed on cycle day #3

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31
Q

With decreasing ovarian reserve (how many eggs), less ____ is secreted

A

inhibin
Inhibin inhibits FSH
Results in increased FSH (>10IU/L associated with diminished ovarian reserve)

32
Q

serum FSH >10 mIU/mL indicates ?

A

significant loss of ovarian reserve

33
Q
  • Measure with serum FSH
  • Due to increase FSH with decreasing ovarian reserves there will be a increasing estradiol level
  • > 80 pg/mL is abnormal
A

Serum Estradiol

34
Q
  • Expressed by granulosa cells of small preantral follicles
  • Possible role in recruitment of the dominant follicle
  • Levels correlate with ovarian primordial follicle number
  • < 1ng/mL associated with diminished ovarian reserve
A

Antimullerian Hormone (AMH)

35
Q

increase Antimullerian Hormone (AMH)
= more ?

A

follicles

36
Q

tx ovulatory dysfunction

A
  1. If something is abnormal, FIX IT!
  2. Hyperprolactinemia
    - Fasting during testing?
    - If no identified cause, check head MRI - r/o micro/macroadenoma
    - Tx: Dopamine agonists - Bromocriptine or Cabergoline; Surgery
  3. Hypothyroidism
    - CC oligomenorrhea and amenorrhea
    — Even subclinical hypothyroidism can cause problem
    - Tx: Levothyroxine
  4. Diminished Ovarian reserve
    - Ovulation Induction
    - IUI/IVF
    - Egg Donor
37
Q

3 ovulation induction options

A
  1. Clomiphene Citrate (Clomid)
  2. Aromatase Inhibitors - Letrozole
  3. Gonadotropins
38
Q
  • Initial tx for most anovulatory infertile women
  • Estrogen antagonist - results in increase in FSH levels which increase ovarian follicular activity
  • Oral medication
  • Given for 5 days starting on cycle day 2-5

which induction option

A

Clomiphene Citrate (Clomid)

39
Q
  • Inhibits the production of estrogens, so it increases FSH
  • Oral medication
  • Given on cycle day 3-7

which induction option

A

Aromatase Inhibitors - Letrozole

40
Q
  • Urinary or recombinant FSH and LH
  • Variety of preparations
  • Typically intramuscular or subcutaneous injections
  • Expensive!

which induction option

A

Gonadotropins

41
Q

Complications of ovulation induction

A
  1. Multifetal gestation
  2. Ovarian hyperstimulation syndrome
42
Q
  • Clinical symptom complex associated with ovarian enlargement resulting from exogenous gonadotropin therapy
  • Due to increased capillary permeability
A

Ovarian hyperstimulation syndrome

43
Q

s/s and tx for Ovarian hyperstimulation syndrome

A
  • Sx - Abdominal pain/distension, ascites, GI problems, respiratory compromise
  • Clinical diagnosis
  • Treatment - Supportive!
44
Q

what is Intrauterine Insemination (IUI)

A
  1. Sperm is washed and concentrated
  2. Long, thin catheter threaded through the cervical os into the endometrial cavity
  3. Sperm injected into endometrial cavity
45
Q

what is In Vitro Fertilization (IVF)

A
  1. Mature oocytes from stmulated ovaries are retrieved transvaginally with sonographic guidance
  2. Sperm and ova are combined in vitro
  3. Viable embryos are transferred transcervically into the endometrial cavity using sonographic guidance
46
Q

tubal and pelvic factors of infertility

A
  1. Dysmenorrhea of chronic pelvic pain may suggest
  2. Adhesions prevent normal tube movement, ovum pickup and transport of fertilized egg into the uterus
47
Q

causes of tubal and pelvic infertility factors

A
  1. Pelvic infection - Increase in the occurrence of PID, increases the risk of adhesions and infertility
  2. Endometriosis
  3. Prior pelvic surgery
48
Q

diagnostic testing for tubal and pelvic infertility factors

A
  1. Hyserosalpingogram (HSG)
    $327-1085
    - Injection of a radio-opaque medium thru cervical canal to evaluate the uterine cavity and tubes
    - Usually perform on cycle day 5-10
  2. Chromopertubation
    - Injection of methylene blue thru cervical canal during laparoscopy to evaluate tubal patency
49
Q

tx tubal and pelvic factors

A
  1. Tubal Occlusion
    - Tubal cannulation - Catheter threaded through the tube to create patency
    - Tubal Reconstruction
    - Tubal Resection - Proceed with IVF afterward
  2. Endometriosis
    - Surgery - Removal of adhesions; Drainage of endometriomas
    - IVF
    - GnRH = long term tx may improve later outcomes
  3. Pelvic adhesions
    - Surgical removal
    - IVF
50
Q

causes of uterine factors

A
  1. Congenital anomalies – uterine septums, mullerian anomalies
  2. Endometrial polyps
  3. Fibroids
  4. Asherman’s syndrome
51
Q

dx and tx for endometrial polyps

A
  • Diagnosis - hysteroscopy
  • Treatment – hysteroscopic removal
52
Q

what are fibroids?
dx and tx?

A
  • Can obstruct a fallopian tube, distort the uterine cavity or fill the uterine cavity
  • Endometrium overlying is less vascular
  • Diagnosis – HSG, ultrasound
  • Treatment - >5cm may consider myomectomy or hysteroscopic resection
53
Q

what is Asherman’s syndrome
dx and tx?

A
  • Intrauterine adhesions
  • Occurs most often with a history of having a D&C
  • dx – HSG or hysteroscopy
  • tx – hysteroscopic lysis of adhesions
54
Q

diagnostic testing for uterine infertility factors

A

Endometrial bx

  • Adequate progesterone levels are required for endometrial preparation prior to implantation
  • Thought to provide more info then serum progesterone alone
  • Thought to have little predictive value and no longer considered routine part of infertility evaluation
55
Q

pros and cons of endometrial bx

A
  • Benefits: can evaluate luteal phase
  • Limitations: Intraobserver bias and interobserver variability, Painful!
56
Q

what secretes mucus? how is that important for the sperm

A
  • Cervical glands secrete mucus
  • Mid-cycle high estrogen levels cause mucous to become thin and stretchy
  • Creates reservoir for sperm
57
Q

causes of cervical infertility factors

A
  • History of LEEP or cone surgery
  • Cryosurgery
  • Cervical infection
58
Q

diagnostic for cervical factors and how to perform

A

Postcoital test

  • Couple has intercourse on day of ovulation
  • Women present to office a few hours later and a sample of cervical mucus is obtained
59
Q

indications of appropriate cervical mucus

A
  1. Mucus should stretch >5cm
  2. Should visualize at least 4 motile sperm on microscopy
  3. Minimal inflammatory cells on microscopy
  4. Dried mucus should form a ferning pattern
60
Q

tx cervical infertility factors

A

IUI

61
Q

male infertility hx factors

A
  1. Pubertal development
    - Hypospadias
    - Cryptorchidism – failure of testes to descend
  2. Sexual function difficulties
    - ED - May indicate decreased testosterone
    - Ejaculatory dysfunction
  3. STDs – epididymitis, prostatis
  4. Mumps - Can lead to testicular inflammation and damage to spermatogenic stem cells
  5. Testicular trauma
  6. Testicular torsion
  7. Varicocele - Dilated veins of the pampiniform plexus of the spermatic cords that drain the testes
62
Q

Takes how long from stem cell to mature sperm

A

90 days

  • 70 days to produce sperm
  • Additional 12-21 days for sperm to travel into the epididymis
  • Any detrimental affect in the prior 3 months can be an issue
  • Occurs best at temperature slightly below body temperature - Illness with high fevers or chronic hot tube use can impair sperm quality
63
Q

causes of male infertility

A
  • Abnormalities of sperm production
  • Abnormalities of sperm function
  • Obstruction of ductal outflow tract
64
Q

how to perform semen analysis

A
  1. Male should refrain from ejaculation for 2-3 days
  2. Specimen collected in sterile cup
65
Q

semen analysis can also evaluate for ?
tx?

A

Antisperm antibodies

  • Antibodies block fertilization
  • Presence of sperm agglutination on analysis should prompt testing for antisperm antibodies
  • tx: Corticosteroids
66
Q

semen analysis - semen low volume indication

A

Low volume – this is for Urology

  1. Could be due to inappropriate collection or short abstinence interval
  2. Can indicate:
    - Partial or complete obstruction of vas deferens - infection, tumor or prior surgery or trauma
    - Retrograde ejaculation - failed closure of the bladder neck during ejaculation; Seminal fluid flows backward into bladder
    — Check UA = detect sperm in urine
67
Q

tx for oligospermia

A
  • < 20 million sperm/mL
  • tx: IUI
68
Q

causes and tx for azoospermia

A

no sperm

  1. Causes:
    * Congenital absence of vas deferens (Cystic Fibrosis)
    * Severe infection
    * Vasectomy
  2. Treatment:
    * Sperm donor
    * Epididymal aspiration or testicular biopsy with sperm aspiration
69
Q

what is Asthenospermia
causes and tx?

A

decreased sperm motility

  1. Causes
    * Prolonged abstinence
    * Antisperm antibodies
    * Infection
    * Varicocele
  2. Tx: Intracytoplasmic sperm injection
70
Q

what is Teratospermia?
tx?

A
  • abnormal sperm morphology
  • IVF
71
Q

Abnormal semen analysis is indication for ?

A

referral to infertility specialist!

72
Q

causes of antisperm ab?

A
  • Vasectomy
  • Testicular torsion
  • Testicular biopsy
  • Situations where the blood-testis barrier is breached
73
Q

hormone evalution for infertility

A
  1. Prolactin, TSH
  2. FSH, Testosterone
74
Q

Low FSH, Low testosterone is indicative of what?
tx?

hormone eval

A
  • Kallmann syndrome: Anosmia associated with hypogonadotropic hypogonadism
  • Idiopathic hypogonadotropic hypogonadism
  • Treatment: Gonadotropins
75
Q

Elevated FSH, Low testosterone is indicative of what? tx?

hormone eval

A

Testicular failure

  1. Oligospermia
    - Replacement testosterone will decrease gonadotropin stimulation of remaining testicular function so should not be used until fertility tx completed (testosterone can make man never make sperm)
76
Q

a common cause of abnml semen characteristics

A

genetic abnormalities

77
Q

Karyotype indicated for men who ?

A

for men with poor semen analysis results

78
Q

causes of genetic abnormalities that warren genetic testing

A
  1. Klinefelter syndrome (47 XXY)
    - Characteristics: Tall, undervirilized men; Gynecomastia
  2. Microdeletion of Y chromosome
    - Can result in unviable sperm
  3. Cystic Fibrosis
    - Congenital absence of vas deferens = obstructive azoospermia
    - Mutations in CFTR gene
    - Tx: Epididymal aspiration to obtain sperm for IVF

Women's health (15 decks)

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