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Womens Health Exam 3 > Infertility > Flashcards

Infertility Flashcards

1
Q

Infertility Definition

A

● Infertility is the inability to conceive after unprotected intercourse for 1
year for patients less than 35 years old or 6 months for patients >35
years old
● >40yo → immediate treatment

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2
Q

Primary vs. secondary infertility

A

○ Primary: a pregnancy has never been achieved
○ Secondary: at least one prior pregnancy has been achieved

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3
Q

Other considerations or reasons to refer a patient for infertility

A

○ PCOS or anovulation
○ Endometriosis
○ Recurrent pregnancy loss (RPL)
○ Same sex couples
○ Transgender patients
○ Cancer patients

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4
Q

Fecundability rate =

A

probability of achieving pregnancy each month
○ <32yo: ~20-25%
○ 35yo: 12%
○ 38yo: 5%
○ 40yo: 3%

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5
Q

Epidemiology of infertility

A

● 1 in every 6 women
○ 25% male factors
○ 25% female factors
○ 35% combined infertility
○ 15% unexplained infertility

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6
Q

Risk Factors for infertility

A

● Maternal age
● Extreme weight loss or weight gain
● Inadequate diet
● Tobacco/Marijuana
● Vaginal lubricants
● PCOS
● Endometriosis

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7
Q

Causes of Female Infertility - cervical

A

○ 5-10%
■ Stenosis
■ Abnormalities of mucus-sperm interaction

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8
Q

Causes of Female Infertility - uterine

A

○ Congenital abnormalities
■ Uterine septum
■ Bicornuate uterus
○ Mullerian anomalies
■ Ex: Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome
○ Leiomyoma
○ Polyps
○ Uterine synechiae
■ Asherman’s syndrome
○ Diethylstilbestrol (DES)

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9
Q

Diethylstilbestrol (DES)

A

■ DES: a synthetic form of the estrogen that was prescribed to pregnant women between
1940 and 1971 to prevent miscarriage, premature labor, and related complications of
pregnancy
■ DES caused serious birth defects during genital formation

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10
Q

Causes of Female Infertility - ovarian

A

Hypothalamic-pituitary-ovarian axis dysfunction
■ Hypogonadism
■ Pituitary adenomas
■ Eating disorders
○ Ovulatory dysfunction
■ Often will have amenorrhea
■ PCOS
● MCC of infertility d/t anovulation
■ Diminished Ovarian Reserve/ Premature Ovarian Insufficiency
○ Gonadal dysgenesis
■ Turner syndrome
○ Chromosomal abnormalities
○ Ovarian cysts (Ex: endometriomas)

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11
Q

Hypothalamic-pituitary-ovarian axis dysfunction includes:

A

■ Hypogonadism
■ Pituitary adenomas
■ Eating disorders

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12
Q

Ovulatory dysfunction includes:

A

■ Often will have amenorrhea
■ PCOS
● MCC of infertility d/t anovulation
■ Diminished Ovarian Reserve/ Premature Ovarian Insufficiency

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13
Q

Tubal Factor

A

○ After ovulation, the fimbriae pick up the oocyte from the peritoneal fluid in the
cul-de-sac
○ Epithelial cilia transport the oocyte up to the ampulla
○ The spermatozoa are transported from the endometrium and advanced through the
fallopian tube down into the ampulla, where fertilization occurs

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14
Q

Abnormalities or damage to fallopian tube

A

■ History of infection (chlamydia/gonorrhea, PID)
■ Previous pelvic surgeries (esp. appendectomy)
■ Endometriosis
■ Ectopic pregnancy
■ Hydrosalpinx
■ Tubal ligation

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15
Q

Rotterdam criteria for PCOS

A

○ Patient must meet 2 of the 3 following criteria:
■ Oligomenorrhea or anovulation
■ Hyperandrogenism (biochemical or clinical signs)
■ PCO appearing ovaries on ultrasound → >12 follicles measuring 2-9mm on at least one ovary

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16
Q

Considerations for patients with PCOS

A

○ Check for early onset diabetes
○ Protect the uterus - patients should either be on OCP’s or cyclic Provera if they are
not having menses and not trying to become pregnant

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17
Q

Endometriosis

A

● Endometriosis is a disease where the endometrial tissue
grows outside of the uterine cavity
● Found in 6-10% of the general female population.
● This can cause severe pelvic pain during menses or
intercourse

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18
Q

Endometriosis etiology

A

● The exact mechanism in which endometriosis affects
fertility is not known
○ Infertile women are 6-8 times more likely to have endometriosis
than women that are fertile.

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19
Q

Endometriosis treatment

A

● Recommended treatment for fertility in patients with
severe Endometriosis
○ Surgery, if necessary
○ IVF

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20
Q

Recurrent Pregnancy Loss

A

● Recurrent pregnancy loss is defined as 3 consecutive miscarriages prior to 20 weeks gestation
● Warrants the basic infertility workup as well as an RPL work up

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21
Q

Work up for Recurrent Pregnancy Loss

A

○ Genetics: karyotype is ordered looking for translocations
■ Treatment: PGT-testing of the embryo after IVF is completed
○ Autoimmune disorders: rule out antiphospholipid syndrome
■ Affects uterine lining and placenta → implantation
■ Diagnosis
● Labs
○ Anticardiolipin antibodies
○ Lupus anticoagulant
○ Anti-beta2-glycoprotein-1
● If any of the above labs are positive, repeat in 12 weeks
■ Treatment: ASA +/- Lovenox during pregnancy

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22
Q

Accounts for 15-30% of patients seeking fertility care

A

Unexplained Infertility

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23
Q

Treatment for unexplained infertility

A

○ Empirical tx with controlled ovarian hyperstimulation followed by IUI has improved
the pregnancy rate in those patients
○ After 3-4 cycles of IUIs, the chance of pregnancy plateaus

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24
Q

Multiple factors can cause male factor infertility

A
  • Hypothalamic-pituitary-testicular axis dysfunction
    ■ Hypogonadotropic hypogonadism
    ■ Prolactinomas
    *Cushing’s
    ■ Low testosterone → decreased sperm production
    *Testicular dysfunction
    ■ Primary hypogonadism (hypergonadotropic)
    ■ Hx of radiation, infection (mumps), varicoceles
  • Genetic conditions
    ■ Klinefelter’s syndrome
    ■ Androgen insensitivity syndrome
    ■ Congenital absence of the vas deferens
    *Retrograde ejaculation
  • Obstruction in the duct system preventing transportation of sperm
    *Aging
    *Trauma
    *Vasectomy
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25
Q

> 50% of men with this condition have CFTR (cystic fibrosis) gene

A

Congenital absence of the vas deferens

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26
Q

Testosterone use and fertility

A

○ This has become very popular among male patients
○ Causes azoospermia
■ Can be temporary or permanent

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27
Q

50% of infertile couples have some form of ____

A

male factor

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28
Q

It is important that the work up for infertility includes ______

A

BOTH partners
○ History
○ Timing and frequency of intercourse
○ Lubricants
○ Douches
■ “Swaying”
○ Surgical procedures
○ Previous pregnancies (both partners)
○ Medication history

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29
Q

Female history

A

○ Menstrual hx
○ Duration of infertility
○ Obstetric hx
■ Miscarriages
■ Ectopic pregnancies
■ Pregnancy complications
○ Procedures
■ D&C
■ C-section
■ Salpingectomy

30
Q

Ovulatory function factors that are important in a female fertility evaluation

A

○ Basal body temperature
○ Cervical mucus
○ Ovulation predictor kits
○ Mid-luteal progesterone level (Day 21)

31
Q

Infertility Workup

A

● Blood work
● Saline Sonohysterogram
○ screening test for hysteroscopy
● Ovarian antral follicle count (AFC)
● Hysterosalpingogram (HSG)
● Semen analysis

32
Q

Saline Sonohysterogram

A

*Evaluates for abnormalities of the uterine cavity
*Involves inserting a catheter through the cervix into the uterus. Saline is then
introduced into the cavity in order to expand the uterine cavity to visualize
the lining of the uterus

33
Q

Antral follicle count (AFC):

A

The number of follicles on both
ovaries found on ultrasound
○ Best done early in the cycle
○ Helps to determine ovarian reserve
○ Inhibin-B: decreased inhibin B is associated with elevated FSH levels and
decreased oocyte quality

34
Q

AMH (Anti Mullerian Hormone)

A

○ AMH is a hormone that is produced by the granulosa cells of early
developing follicles
○ AMH has been shown to be one of the best markers of ovarian reserve
○ An AMH >1.0 is generally good showing good ovarian reserve, a level of <1.0
can be associated with diminished ovarian reserve

35
Q

Clomiphene challenge

A

○Day 3 FSH level
○Clomiphene 100mg daily on Days 5-9
○Repeat FSH on Day 10
■ Typically you will have a small increase in FSH while taking Clomid. FSH
stimulates the ovaries that then produce estrogen which acts as a negative
feedback loop. Once this feedback occurs, FSH should return to normal by
Day 10
●Increase in FSH = DOR

36
Q

Hysterosalpingogram (HSG)

A
  • HSG: an X-ray test that uses fluoroscopy to outline the uterine cavity and demonstrate if the fallopian tubes are patent
37
Q

Male Evaluation of fertility

A
  • PE
    *Infection
    *Hernia
    *Varicocele
    *Signs of androgen deficiency
    *Testicular mass
  • Labs
    *Endocrine panel (FSH, LH, testosterone, TSH, PRL)
    *↑FSH, ↓ testosterone = primary hypogonadism
    *STI screen
    *Genetic carrier screening
38
Q

Semen Analysis includes these factors:

A

Volume
Count
Motility
Morphology

39
Q

Normal semen volume

A
  • 2.0 mL – 5.0 mL
    ● If too low → can be harder for sperm to get to the cervix
    ● If too high → it may dilute the sperm
40
Q

Normal semen count

A
  • > 20 million/mL
    ● This number can fluctuate greatly for an individual
41
Q

Normal semen motility

A
  • ≥ 50%
    ● Moving sperm in the right direction with motivation
42
Q

Normal semen morphology

A
  • ≥ 14%
    ● Overall shape of the sperm
43
Q

If low semen volume suspect:

A

*Postejaculatory urinalysis
*Retrograde ejaculation
*Transrectal U/S
*Can show obstruction

44
Q

Specialized semen tests

A

*Sperm viability
*Sperm culture
*Sperm biochemistry and fxn
*IgA sperm antibodies interfere with sperm-oocyte
interaction
*IgG sperm antibodies - impaired mobility
*DNA fragmentation

45
Q

Treatment for Male Factor

A
  • Hyperprolactinemia
    *Dopamine agonists (cabergoline, bromocriptine)
  • Protocol for retrograde ejaculation
  • Erectile dysfunction medications if indicated
  • Surgical correction if indicated
    *Blockage of vas deferen
46
Q

Seminal fluid abnormalities treatment

A

specialist referral
*Clomid, hCG or Gonadotropin injections to try to restore function
*Intrauterine insemination (IUI)
*Not as successful with low counts especially <2 million
*In vitro fertilization (IVF)
*Intracytoplasmic sperm injection (ICSI)

47
Q

Testicular sperm extraction (TESE)

A

*After vasectomy
*Can reverse vasectomy but not always successful

48
Q

Depending on results of fertility testing different treatment options are available:

A

● Treat any underlying conditions (thyroid, prolactinoma)
● Ovulation Induction
○Natural cycle vs. Medicated
○Timed intercourse vs. Intrauterine insemination (IUI)
● In vitro fertilization (IVF)
○PGT testing
● Donor Egg or Embryo
● Donor sperm inseminations
● Gestational Carrie

49
Q

Ovulation Induction

A
  • Natural cycle monitoring: monitoring patients follicular growth using
    ultrasound
  • Can opt to have TI (timed intercourse) or IUI if there are any sperm abnormalities
  • Medicated cycles
  • Patients begin taking oral medication (Clomid or Femara)
    beginning Day 3-4
    *Take medication for 5 days (typically)
    *Monitor patients follicle size throughout cycle
    *Plan for TI or IUI
50
Q

Clomid (clomiphene)

A
  • Selective Estrogen Receptor Modulator
  • Binds to estrogen receptors → blocks negative feedback → increases FSH and LH → help follicles in the ovary grow
  • 50-100mg daily
  • SE: mood swings, blurred/double vision
    ● Ovarian hyperstimulation
    ● Risk of multiple gestation
    ● CI: pregnancy, uncontrolled thyroid, AUB
51
Q

Femara (letrozole) - OFF LABEL USE

A
  • Aromatase Inhibitor
  • Blocks aromatase which converts androstenedione to estradiol → lowers estradiol which reduce negative feedback →
    produce more FSH → help follicles in the ovary grow
  • 2.5-7.5mg daily x5 days
  • Risk of multiple gestation
  • Fewer SE than Clomid
    ● Hot flashes, nausea
  • CI: pregnancy, liver dz, osteoporosis, hypercholesterolemia
52
Q

Gonadatropins (FSH, LH containing mediations)

A

*Follistim, Gonal F, Menopur
*These medications work by giving exogenous FSH and LH to stimulate the ovaries

53
Q

hCG (Ovidrel)

A

*“trigger shot”
*This is hcg, the pregnancy hormone. It is given mid-cycle to mimic LH surge. hCG has a
longer half life than LH.
*Causes ovulation to occur about 24-48 hours after giving it. This makes timing of
intercourse or IUI much easier.

54
Q

Intrauterine Insemination

A
  • Intrauterine insemination (IUI) is the process of
    depositing washed, concentrated sperm directly into the uterus using a small catheter
  • IUI will increase the number of healthy sperm that get to the fallopian tubes where the egg will be fertilized
  • Can be done for a variety of reasons: cervical
    stenosis, low sperm count, same-sex couples using donor sperm
55
Q

A good sperm count for IUI is ______

A

> 10 million motile sperm

56
Q

In Vitro Fertilization (IVF)

A
  • IVF is a medical procedure that involves retrieving preovulatory oocytes (eggs) from the female’s ovary and fertilizing them outside of the body to create embryos
  • The goal of IVF is to get multiple eggs to fertilize, potentially creating multiple embryos to choose from
    *Injectable medications are given to stimulate the ovaries to produce as many eggs as
    possible. These medications vary depending on the protocol for that specific patient
    *The eggs are retrieved through a VOR (vaginal oocyte retrieval)
    ■This involves an ultrasound guided needle through the back of the vagina that collects all
    of the fluid and the oocyte that are inside of each follicle
57
Q

The eggs for IVF are retrieved through _____

A

a VOR (vaginal oocyte retrieval)

58
Q

What is the InvoCell?

A

Oocytes and sperm are combined in a small device, which is then placed near the cervix for
incubation

59
Q

ICSI (Intracytoplasmic sperm injection)

A

The most common technique used to help with fertilization
○The best looking sperm is selected, immobilized, and injected into the oocyte for fertilization

60
Q

At this time the embryo needs to be transferred into the uterus or frozen,
it can no longer grow outside of the body

A

After fertilization occurs, the fertilized oocyte will develop into a blastocyst over the next 5 days
○Either within the InvoCell device or in the embryology lab

61
Q

Preimplantation Genetic Testing

A

*A biopsy is taken of the trophectoderm and sent for analysis
*PGT-A: determines if embryo is chromosomally normal as well as gender
*PGT-M: identifies specific genes
■Ex: Cystic fibrosis, Spinal muscular atrophy, thalassemia

62
Q

FROZEN EMBRYO TRANSFER

A
  • Frozen embryo transfer (FET) is the procedure to transfer the embryo into the uterus
  • The uterus is prepared to receive the embryo
  • Most frequently, estrogen is used to thicken the lining
  • At times a natural cycle may also be recommended
  • Once the uterus is ready the patient starts
    progesterone supplementation and the transfer
    is done 5 days later
63
Q

Donor egg:

A

Utilizing an egg from an egg donor with partner’s sperm/ donor sperm and the patient carrying the pregnancy
■Using donor eggs will give the patient the pregnancy chance of the donor (based on age,
follicle count and AMH level). This can significantly improve the chance of pregnancy

64
Q

Donor sperm:

A

Utilizing sperm from a sperm donor with patient’s egg/donor egg and the patient carrying the pregnancy
■Sperm banks
■GCS + CMV status

65
Q

Donor embryo:

A

Utilizing an embryo that has already been created with the patient can carry the pregnancy
* Often time these embryos come from a family that has already had a child or children and
donates their remaining embryos

66
Q

Gestational carriers can be used for various reasons

A

■Health issues for the intended parent that make pregnancy dangerous
■Absence of the uterus
■Same sex male couples
■Age of the intended parent

67
Q

What is Co-IVF?

A

Fertilizing partner’s eggs with donor sperm with other partner carrying pregnancy

68
Q

Same sex female couples IVF options

A

*Timed donor insemination
■Known donor vs anonymous
* Co-IVF
■Fertilizing partner’s eggs with donor sperm with other partner carrying pregnancy

69
Q

Same sex male couples IVF options

A
  • Donor egg with own sperm using gestational carrier
    ■Known donor vs anonymous
70
Q

Oocyte or sperm cryopreservation

A

*Strongly recommended for pts that want to build their family in the future prior to beginning:
*Prior to Cancer treatments including radiation or chemotherapy
*Prior to Hormonal therapy or surgical transition for transgender patients
*Prior to Vasectomy
*Know they want children later d/t career goals
*Do not currently have a partner
*Lower AMH/ovarian reserve for age
*It is recommended to freeze oocytes as early as possible for better improved
quality of eggs

71
Q
A

Womens Health Exam 3 (6 decks)

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