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Women's Health > Infertility > Flashcards

Infertility Flashcards

1
Q

Even without treatment, what percent of women will conceive during the second year of attempting?

A

50%

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2
Q

What is the definition of infertility?

A
  • Inability to conceive after 1 year of unprotected intercourse of reasonable frequency in women <35
  • Inability to conceive after 6 months of unprotected intercourse of reasonable frequency in women >35 yo
  • > 40 yo more immediate evaluation and treatment
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3
Q

What conditions known to cause infertility would warrant more immediate evaluation of infertility?

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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4
Q

What is considered primary infertility? Secondary?

A

Primary: no prior pregnancies
Secondary: following at least one prior conception

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5
Q

What are the most common causes of infertility?

A
  1. Ovulatory
  2. Male
  3. Tubal/uterine
  4. Other
  5. Unexplained

BOTH PARTNERS NEED to be evaluated

If you can’t figure out problem, start on treatment for ovulatory issue

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6
Q

What questions will be asked when assessing infertility?

A
  • Frequency, duration, changes, hot flashes, dysmenorrhea during menstruation
  • Signs of ovulation: cervical mucus changes, ovulation tests, basal body temperatures
  • Prior contraeptive use
  • History of ovarian cysts, endometriosis, leiomyomas, STDs, PID
  • History of abnormal pap smears; conization: can decrease cervical mucus quality and cervical anatomy
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7
Q

What does a prior pregnancy confirm?

A

Ovulation and patent fallopian tube

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8
Q

What pregnancy complications can be helpful in diagnosing infertility?

A
  • Miscarriage
  • Preterm delivery
  • Retained placenta
  • Postpartum D&C
  • Chorioamnionitis
  • Fetal anomalies
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9
Q

What are questions to ask about coital history?

A
  • Frequency
  • Timing: chance of conception increased 5 days preceding ovulation, should have daily intercourse during this period
  • Dyspareunia
  • Lubricants: avoid oil based lubricants, water based preferred
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10
Q

What medical history can impact fertility?

A
  • Chemotherapy
  • Radiation
  • Androgen excess –> PCOS
  • Thyroid disease
  • Hyperprolactinemia
  • Medications
  • BMI: moderate weight reduction in overweight women can normalize menstrual cycles and increase chance of pregnancy
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11
Q

What social history can impact fertility?

A
  • Lifestyle
  • Environmental factors: eating habits, toxins
  • Smoking: lowers fertility in men and women
  • Alcohol
  • Caffeine
  • Illicit drugs
  • Ethnicity: important for pre-conceptional testing
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12
Q

What are key components of infertility 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, mobility
  • Adnexal masses or tenderness
  • Cul-de-sac masses, tenderness, or nodularity
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13
Q

What are common causes of female infertility?

A
  • Ovulatory disorders
  • Endometriosis
  • Pelvic adhesions
  • Tubal blockage or other tubal problems
  • Uterine or cervical factors
  • Unexplained
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14
Q

Genetic testing has a low incidence of abnormalities in female infertility. When should you consider testing?

A
  • History of recurrent pregnancy loss –> 3 or more consecutive loss at <20 weeks gestation or with fetal weight <500 g
  • Premature ovarian failure (<40 yo)
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15
Q

What can cause recurrent pregnancy loss?

A
  • Parental chromosomal abnormalities (aneuploidy, more common in sporadic miscarriages)
  • Antiphospholipid syndrome
  • Uterine abnormalities
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16
Q

What is the most common cause of premature ovarian failure (<40 yo) and a sign of this?

A
  • Turners,menopause occuring at younger age
  • Average normal age of menopause is 51 yo
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17
Q

What can ovulation be affected by?

A

Abnormalities in hypothalamus, pituitary, or ovaries

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18
Q

What are common etiologies of ovulatory dysfunction?

A
  • Hypothyroidism
  • Hyperprolactinemia
  • Diminished ovarian reserve- someone who is older w/o good eggs
  • PCOS
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19
Q

What type of relationship is present between female age and fertility?

A

Inverse relationship

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20
Q

Why does infertility increase as age increases?

A
  • Loss of viable oocytes
  • Risk of genetic abnormalities and mitochondrial deletions in remaining oocytes increases with age –> increased rate of miscarriage
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21
Q

How is ovulatory dysfunction diagnosed?

A
  • Menstrual history: cyclic menses (25-35 days with duration of 3-7 days), Mittleschmerz, Moliminal symptoms (breast tenderness, acne, food cravings, mood changes) good
  • Labs: TSH, FT4, Prolactin
  • Weight: anorexia and bulimia can affect GnRH; obesity can indicate PCOS
  • Basal body temperature: postovulatory rise by .4-.8 F; but insensitive in many women
  • Sonography
  • Ovulation predictor kits
  • Serum progesterone
  • Serum FSH
  • Serum estradiol
  • AMH
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22
Q

How can sonography be used to predict ovulatory dysfunction?

A
  • Serial exams demonstrate maturation of antral follicle and collapse during ovulation
  • Count less than 5-7 can indicate diminished ovarian reserve
  • Benefits: useful in diagnosis of PCOS
  • limitations: time consuming, expensive
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23
Q

How can ovulation predictor kits be used to diagnose ovulatory dysfunction?

A
  • Test concentration of urinary LH
  • Should begin testing 2-3 days before predicted LH surge and continue daily
  • Test with first morning void
  • Ovulation will occur day following urinary LH peak
  • Benefits: some studies shown to have sensitivity of 100%
  • Limitations: expensive
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24
Q

How is serum progesterone used to diagnose ovulatory dysfunction?

A
  • Check progesterone on day 21 in 28 day cycle
  • Can also be checked 7 days following ovulation
  • Serum progesterone: <2 ng/mL
  • > 3 ng/mL indicative of ovulation (progesterone produced by corpus luteum)
  • Benefits: easy to do
  • Limitations: progesterone secreted in pulses and single measurement may not be indicative of overall production
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25
Q

How is serum FSH used to diagnose ovulatory dysfunction?

A
  • Sensitive predictor of ovarian reserve
  • With decreasing ovarian reserve, less inhibin secreted
  • Inhibin inhibits FSH resulting in increased FSH
  • Typically performed on cycle day #3
  • > 10 mIU/mL indicates significant loss of ovarian reserve
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26
Q

How is serum estradiol used to diagnose ovulatory dysfunction?

A
  • Measure with serum FSH
  • Due to increase FSH with decreasing ovarian reserves, will have increasing estradiol level (overcompensating)
  • > 80 pg/mL is abnormal
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27
Q

How is antimullerian hormone used to diagnose ovarian dysfunction?

A
  • Expressed by granulosa cells of small preantral follicles
  • Possible role in recruitment of dominant follicle
  • Levels correlate with ovarian primordial follicle number
  • In PCOS, may be 2-3 fold increase in levels
  • <1 ng/mL associated with diminished ovarian reserve
  • INCREASED AMH = MORE FOLLICLES
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28
Q

What is treatment for hyperprolactinemia leading to ovarian dysfunction?

A
  • Fasting during testing?
  • If no identified cause, check head MRI to identify micro/macroadenoma
  • Treatment with dopamine agonists –> bromocriptine or cabergoline
  • Surgery
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29
Q

What are effects of hypothyroidism on ovulation? What is treatment?

A

Effects: Oligomenorrhea and amenorrhea, even subclinical can cause problem
Treatment: levothyroxine

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30
Q

What is treatment for diminished ovarian reserve?

A
  • Ovulation induction
  • IUI/IVF
  • Egg donor
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31
Q

What is used for ovulation induction?

A
  • Clomiphene citrate
  • Aromatase inhibitors –> Letrozole
  • Gonadotropins
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32
Q

What is the initial treatment for most anovulatory infertile women?

A

Ovulation induction with clomiphene citrate

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33
Q

What is the mechanism of action of clomiphene citrate?

A
  • Oral medication given for 5 days starting on cycle day 2-5
  • Estrogen antagonist that results in increase in FSH which increases ovarian follicular activity
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34
Q

What is the mechanism of action of aromatase inhibitors (Letrozole)?

A
  • Oral medication given cycle day 3-7
  • Inhibits the production of estrogens, so it increases FSH
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35
Q

What is the mechanism of action of gonadotropins?

A

Urinary or recombinant FSH and LH given intramuscular or SQ
Expensive though!

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36
Q

What are complications of ovulation induction?

A
  • Multifetal gestation–> increase in obstetrical outcomes
  • Ovarian hyperstimulation syndrome
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37
Q

What is ovarian hyperstimulation syndrome?

A

Clinical symptom complex associated with ovarian enlargement resulting from exogenous gonadotropin therapy due to increased capillary permeability

38
Q

What are symptoms of ovarian hyperstimulation syndrome?

A
  • Abdominal pain/distension
  • Ascites
  • GI problems
  • Respiratory compromise
39
Q

How is ovarian hyperstimulation syndrome diagnosed and treated?

A
  • Clinical diagnosis and supportive treatment
40
Q

What is intrauterine insemination?

A
  • Sperm washed and concentrated
  • Long thin catheter threaded through cervical os into endometrial cavity
  • Sperm injected into endometrial cavity
41
Q

What is in vitro fertilization?

A
  • Mature oocytes from stimulated ovaries are retrieved transvaginally with sonographic guidance
  • Sperm and ova combined in vitro
  • Viable embryos transferred transcervially into endometrial cavity using sonographic guidance
42
Q

What are tubal and pelvic factors impacting fertility?

A
  • Dysmenorrhea of chronic pelvic pain may suggest adhesions that prevent normal tube movement, ovum pickup, and transport of fertilized egg into uterus
43
Q

What are etiologies of adhesions causing infertility?

A
  • Pelvic infection: increase in occurance of PID, increasing risk of adhesions and infertility
  • Endometriosis
  • Prior pelvic surgery
44
Q

What is diagnostic testing for tubal and pelvic factors impacting fertility?

A
  • Hyserosalpingogram
  • Chromopertubation
45
Q

What is hyserosalpingogram?

A
  • Injection of radio-opaque medium through the cervical canal to evaluate uterine cavity and tubes
  • Usually performed on cycle day 5-10
46
Q

What is chromopertubation?

A
  • Injection of methylene blue through cervical canal during laparoscopy to evaluate tubal patency
47
Q

What is treatment for tubal occlusion?

A
  • Tubal cannulation: catheter threaded through tube to create patency
  • Tubal reconstruction
  • Tubal resection: proceed with IVF after
48
Q

What is treatment for endometriosis?

A
  • Surgical treatment via removal of adhesions and drainage of endometriomas
  • IVF
  • GnRH –> long term treatment may improve later outcomes
49
Q

What is treatment for pelvic adhesions?

A
  • Surgical removal
  • IVF
50
Q

What is etiology for uterine factors impacting fertility?

A
  • Congenital anomalies: uterine septums, mullerian anomalies
  • Endometrial polyps
  • Fibroids
  • Asherman’s syndrome
51
Q

What is the diagnosis and treatment of uterine factors?

A
  • Diagnosis: hysteroscopy
  • Treatment: hysteroscopic removal
52
Q

How can fibroids cause infertility?

A
  • Can obstruct fallopian tube, distort uterine cavity or fill the uterine cavity
  • Endometrium overlying is less vascular
53
Q

How are fibroids diagnosed and treated?

A
  • Diagnosis: HSG, ultrasound
  • Treatment: >5 cm may consider myomectomy or hysteroscopic resection
54
Q

What is asherman’s syndrome?

A

Intrauterine adhesions that occur most often with a history of having a D&C

55
Q

How is asherman’s syndrome diagnosed and treated?

A
  • Diagnosed: HSG or hysteroscopy
  • Treatment: hysteroscopic lysis of adhesions
56
Q

How are uterine factors influencing fertility diagnosed?

A
  • Endometrial biopsy
57
Q

How are endometrial biopsies used for infertility?

A

Throught to provide more information about adequate progesterone levels for endometrial preparation prior to implantation

Benefits: can evaluate luteal phase
Limitations: intraobserver bias and interobserver variability, painful

No longer considered routine part of infertility evaluation!

58
Q

How do cervical glands influence fertility?

A

Mid-cycle high estrogen levels cause mucous to become thin and stretchy and create reservoir for sperm

59
Q

What is the cause of cervical abnormalities leading to infertility?

A
  • History of LEEP or cone surgery
  • Cryosurgery
  • Cervical infection
60
Q

How are cervical factors influencing fertility diagnosed?

A
  • Postcoital test
61
Q

What is a postcoital test?

A
  • Couple has intercourse on day of ovulation
  • Women present to office a few hours later and a sample of cervical mucus is obtained
62
Q

What are indications of appropriate mucus on postcoital test?

A
  • Mucus should stretch >5 cm
  • Should visualize at least 4 motile sperm on microscopy
  • Minimal inflammatory cells on microscopy
  • Dried mucus forms ferning pattern
63
Q

What is treatment for cervical factors influencing fertility?

64
Q

What are causes of male infertility?

A
  • Pubertal development: hypospadias, cryptorchidism
  • Sexual function difficulties: erectile dysfunction (may indicate decreased testosterone) and ejaculatory dysfunction
  • STDs - epididymitis, prostatis
  • Mumps: can lead to testicular inflammation and damage to spermatogenic stem cells
  • Testicular trauma
  • Testicular torsion
  • Varicocele: dilated veins of pampiniform plexus of the spermatic cords that drain the testes
65
Q

What are factors that influence spermatogenesis?

A

Any detrimental effect in last 3 months can cause issue (takes 90 days to mature sperm)
* Occurs best at temperature slightly below body temperature: illness with high fevers or chronic hot tub use can impair sperm quality

66
Q

What are causes of male infertility?

A
  • Abnormalities of sperm production
  • Abnormalities of sperm function
  • Obstruction of ductal outflow tract
67
Q

What are components of semen analysis?

A
  • Male should refrain from ejaculation for 2-3 days
  • Specimen collected in sterile cup
  • Volume, count, motility, morphology, WBCs, and round cells analyzed
  • If round cells are high may not have enough mature sperm
  • Can also evaluate for antisperm antibodies
68
Q

What are antisperm antibodies?

A
  • Present in 4-8% of infertile men
  • Antibodies block fertilization
69
Q

What should you do if sperm agglutination is present on analysis?

A

Test for antisperm antibodies

70
Q

How is antisperm antibodies treated?

A

Corticosteroids

71
Q

What can low semen volume indicate?

A
  • Inappropriate collection or short abstinence interval
  • Partial or complete obstruction of vas deferens due to infection, tumor, or prior surgery or trauma
  • Retrograde ejaculation due to failed closure of bladder neck during ejaculation causing seminal fluid to flow backward
72
Q

If retrograde ejaculation is occuring, what will you see?

A

Sperm in urine on UA

73
Q

What is oligospermia and how is it treated?

A
  • <20 million sperm/mL
  • Treatment: IUI
74
Q

What is azospermia?

A

No sperm, occurs in 1% of men

75
Q

What are causes of azoospermia?

A
  • Congenital absence of vas deferens
  • Severe infection
  • Vasectomy
76
Q

What is treatment for azoospermia?

A
  • Sperm donor
  • Epididymal aspiration or testicular biopsy with sperm aspiration
77
Q

What is asthenospermia?

A

Decreased sperm motility

78
Q

What are causes of asthenospermia?

A
  • Prolonged abstinence
  • Antisperm antibodies
  • Infection
  • Varicocele
79
Q

What is treatment for asthenospermia?

A

Intracytoplasmic sperm injection

80
Q

What is teratospermia and how is it treated?

A
  • Abnormal sperm morphology treated with IVF
81
Q

Abnormal semen analysis is indication for what?

A

Referral to infertility specialist

82
Q

When are antisperm antibodies prevalent and how are they treated?

A
  • Vasectomy
  • Testicular torsion
  • Testicular biopsy
  • Situations where the blood-testis barrier is breached
  • Treated with corticosteroids
83
Q

What hormones can be evaluated for infertility in men?

A
  • Prolactin, TSH
  • FSH, testosterone
84
Q

What could cause low FSH, low testosterone and how is it treated?

A
  • Kallmann syndrome: anosmia associated with hypogonadotropic hypogonadism
  • Idiopathic hypogonadotropic hypogonadism
  • Treatment: gonadotropins
85
Q

What could cause elevated FSH, low testosterone?

A
  • Testicular failure –> oligospermia
  • Replacement testosterone will decrease gonadotropin stimulation of remaining testicular function so should not be used until fertility treatment completed (testosterone can actually make man never make sperm)
86
Q

If men have poor semen analysis results, what is indicated?

87
Q

What are causes of abnormal semen characteristics?

A
  • Klinefelter syndrome (47 XXY)
  • Microdeletion of Y chromosome
  • Cystic fibrosis
88
Q

What are characteristics of men with Klinefelter syndrome?

A
  • Tall, undervirilized men
  • Gynecomastia
89
Q

What can microdeletion of Y chromosome cause?

A

Unviable sperm

90
Q

How does cystic fibrosis impact male fertility?

A
  • Congenital absence of the vas deference causing obstructive azoospermia
  • Mutations in CFTR gene
91
Q

How is infertility due to cystic fibrosis treated?

A

Epididymal aspiration to obtain sperm for IVF

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