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Special Populations > Infertility > Flashcards

Infertility Flashcards

1
Q

When does the American Society of Reproductive Medicine say it is appropriate to treat infertility?

A
  1. failure to achieve successful pregnancy after 12 months or more if appropriate, timed intercourse or therapeutic donor insemination
  2. If over the age of 35, early evaluation and treatment may be considered after 6 months
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2
Q

What are primary causes of infertility?

A
  1. primary ovarian insufficiency (premature ovarian failure)
  2. PCOS
  3. obesity
  4. weight changes
  5. excessive exercise
  6. thyroid dysfunction
  7. hyperprolactinemia
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3
Q

What day of the cycle is menses?

A

day 0

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4
Q

What day of the cycle is ovulation?

A

day 14

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5
Q

What causes ovulation?

A

LH surge

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6
Q

What is true for basal temperature family planning to be effective?

A

must be laying in bed without a blanket or anything increasing temperature

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7
Q

What is an ectopic pregnancy?

A

implantation in the fallopian tube

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8
Q

How long is the egg viable for fertilization after ovulation?

A

24h

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9
Q

How long is sperm viable for fertilization?

A

5-7 days

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10
Q

What should be used to monitor the exact time of ovulation?

A

ovulation testing kits

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11
Q

What medications increase prolactin levels?

A
  1. chlorpromazine
  2. cimetidine
  3. estrogen
  4. haloperidol
  5. medroxyprogesterone acetate
  6. methyldopa
  7. TCA
  8. Varapamil
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12
Q

What medications decrease sperm activity?

A
  1. cocaine
  2. marijuana
  3. anabolic steroids
  4. alcohol (excess)
  5. allopurinol
  6. CCBs
  7. caffeine
  8. colchicine
  9. nitrofurantoin
  10. Spironolactine
  11. tetracycline
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13
Q

Who should be tested first to determine infertility?

A

male

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14
Q

What kind of testing is done for women to determine infertility?

A
  1. thyroid function tests
  2. LH detection
  3. serum progesterone
  4. prolactin
  5. FSH
  6. estradiol
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15
Q

What hormone is produced by granulosa cells of early follicles, is gonadotropin independent, and remains constant between cycles?

A

serum antimullerian horomone

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16
Q

What is nonpharm treatment for infertility?

A
  1. avoid contributing medications (nicotine, alcohol, illicit drugs)
  2. BMI< 27 (weight reduction of 5% ay restore spontaneous ovulation)
  3. avoid excess exercise and dieting
  4. multivitamin with folic acid
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17
Q

How is hyperprolactinemia treated?

A
  1. bromocriptine
  2. cabergoline
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18
Q

What is first line for infertility?

A

Clomiphene citrate (CLOMID)

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19
Q

What is the MOA of Clomid?

A

estrogen antagonist –> inhibits negative feedback –> increases release of gonadotropins (FSH) from pituitary

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20
Q

How is Clomid dosed?

A

PO on days 5-9 of the cycle; increase by 25-50 mg/day till ovulation occurs

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21
Q

How long can a patient be on Clomid? Why?

A
  1. consider another therapy after 6 cycles with no pregnancy
  2. > 12 months use increases risk of ovarian cancer
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22
Q

What are SEs with Clomid?

A
  1. vaginal dryness and moodiness
  2. abdominal discomfort
  3. visual disturbances
  4. thickening cervical mucus
23
Q

What are positive predictors of Clomid working?

A
  1. age <30
  2. history of amenorrhea vs. oligomenorrhea
24
Q

What is the MOA of Letrozole (FEMARA) and Anastrozole (ARIMIDEX)?

A

competitive inhibitor of aromatase prevents conversion of androgen to estrogen –> lower estrogen signals the hypothalamus to release FSH and LH

25
Q

How are Letrozole (FEMARA) and Anastrozole (ARIMIDEX) dosed?

A

PO on cycle days 3-7

26
Q

What are SEs with Letrozole (FEMARA) and Anastrozole (ARIMIDEX)?

A
  1. vasomotor symptoms
  2. headache
  3. breast tenderness
27
Q

What medications can be combined with Letrozole (FEMARA) and Anastrozole (ARIMIDEX)?

A

gonadotropins

28
Q

What medication can be combined with Clomid in women with PCOS?

A

Metformin

29
Q

How long does it take for Metformin to show the effect on ovulation?

A

6 months

30
Q

What are ADRs with Metformin?

A

Abdominal symptoms, counseling point

31
Q

When should exogenous gonadotropins be used for infertility?

A

non responsive to Clomid

32
Q

What is the MOA of gonadotropins?

A

used in conjunction with hCG (ovulation trigger); causes transient increase in FSH which exceeds FSH threshold for ovarian stimulations

33
Q

What gonadotropin agents are used for infertility?

A
  1. Human menotropins (REPONEX)- purified FSH and LH
  2. Urofollitropin (BREVELLE)- purified FSH
  3. Follitropin alfa (GONAL-F) and Follitropin beta (FOLLISTIM)- recombinant FSH
34
Q

What are SEs with gonadotropins?

A
  1. hot flashes, breast tenderness and abdominal pain, N/D (10%)
  2. injection site reaction
  3. dry skin, rash, alopecia, hives
  4. OHSS
    *Additive when used with other products
  5. false positive pregnancy tests due to hCG
35
Q

What is ovarian hyperstimulation syndrome?

A

rare life-threatening complications (kidney failure, thrombosis, stroke); excessive response to ovulation induction therapy

36
Q

How does ovarian hyperstimulation syndrome usually present?

A

severe cramping

37
Q

What are other s/s of OHSS?

A

Mild:
1. abdominal discomfort
2. N/V/D
Severe:
1. hemodynamic instability
2. ascites
3. severe pain
4. dyspnea and tachypnea

38
Q

What should be done if ovarian hyperstimulation syndrome occurs?

A
  1. stop gonadotropin cycle; withhold hCG (ovulation trigger)
  2. supportive care
39
Q

What is preferred dosing of gonadotropins?

A

Step up therapy:
1. based on bloodwork NOT day of cycle
2. start low and increase as tolerated
3. dose increases is based on follicular development
4. dose is maintained until ovulation trigger administered
(37.5-75 IU QD x 14 days, then increase by 37.5-75 IU weekly, max. 225 IU QD)

40
Q

When might FSH as initial therapy be preferred over Clomid?

A

anovulation caused by PCOS

41
Q

What is the MOA of chorionic gonadotropin?

A

used with hCG; mimics LH (final stage of follicular development and ovulation)

42
Q

When are chorionic gonadotropin (LH) used?

A

used after gonadotropins for ovulation induction

43
Q

What agents are chorionic gonadotropins (LH) used for infertility?

A
  1. NOVAREL
  2. OVIDREL
  3. PREGNYL
44
Q

What are SEs with chorionic gonadotropins (LH)?

A
  1. enlargement/ rupture of cysts
  2. headache
  3. irritability
  4. fatigue/restlessness
  5. edema
  6. injection site reactions (10-13%)
  7. false positive pregnancy tests due to hCG
45
Q

When are GnRH agonists and antagonists used?

A

IVF or assistive reproductive technologies ( cycle syncing for surrogate)

46
Q

What is the MOA of Leuprolide (LUPRON and Naferelin (SYNAREL)?

A

GnRH agonist; suppresses a premature LH surge

47
Q

What are SEs with Leuprolide (LUPRON and Naferelin (SYNAREL)?

A
  1. hot flashes
  2. mood swings
  3. breast tenderness
  4. injection site reactions
  5. OHSS
  6. pituitary impression
  7. inadequate LH to promote endometrial growth to support early pregnancy
48
Q

What is the MOA of Cetrorelix (CETROTIDE) and Ganirelix (ANTAGON)?

A

GnRH antagonist; supresses premature LH surge

49
Q

What are SEs with Cetrorelix (CETROTIDE) and Ganirelix (ANTAGON)?

A
  1. hot flashes
  2. mood swings
  3. breast tenderness
  4. injection site reactions
  5. OHSS
  6. pituitary impression
  7. inadequate LH to promote endometrial growth to support early pregnancy
50
Q

What is used to support implantation and early pregnancy if inadequate LH concentrations?

A

Progesterone first 8-10 weeks of pregnancy (IM or intravaginal)

51
Q

What is another use of Progesterone for treating infertility?

A

used PO for menstrual induction (10-14 days then withdrawal)

52
Q

What needs to be monitored when using pharmacotherapies to treat infertility?

A
  1. ultrasounds every 24-48h
  2. serum estradiol (guide to dosing gonadotropins and hCG)
53
Q

Why is it important to note the risk of multiples when treating infertility?

A

multiples increase the risk of:
1. gestational diabetes
2. preeclampsia
3. premature labor/ delivery

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