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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
>50% of men with this condition have CFTR (cystic fibrosis) gene
Congenital absence of the vas deferens
26
Testosterone use and fertility
○ This has become very popular among male patients ○ Causes azoospermia ■ Can be temporary or permanent
27
50% of infertile couples have some form of ____
male factor
28
It is important that the work up for infertility includes ______
BOTH partners ○ History ○ Timing and frequency of intercourse ○ Lubricants ○ Douches ■ “Swaying” ○ Surgical procedures ○ Previous pregnancies (both partners) ○ Medication history
29
Female history
○ Menstrual hx ○ Duration of infertility ○ Obstetric hx ■ Miscarriages ■ Ectopic pregnancies ■ Pregnancy complications ○ Procedures ■ D&C ■ C-section ■ Salpingectomy
30
Ovulatory function factors that are important in a female fertility evaluation
○ Basal body temperature ○ Cervical mucus ○ Ovulation predictor kits ○ Mid-luteal progesterone level (Day 21)
31
Infertility Workup
● Blood work ● Saline Sonohysterogram ○ screening test for hysteroscopy ● Ovarian antral follicle count (AFC) ● Hysterosalpingogram (HSG) ● Semen analysis
32
Saline Sonohysterogram
*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
Antral follicle count (AFC):
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
AMH (Anti Mullerian Hormone)
○ 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
Clomiphene challenge
○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
Hysterosalpingogram (HSG)
* HSG: an X-ray test that uses fluoroscopy to outline the uterine cavity and demonstrate if the fallopian tubes are patent
37
Male Evaluation of fertility
* 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
Semen Analysis includes these factors:
Volume Count Motility Morphology
39
Normal semen volume
* 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
Normal semen count
* > 20 million/mL ● This number can fluctuate greatly for an individual
41
Normal semen motility
* ≥ 50% ● Moving sperm in the right direction with motivation
42
Normal semen morphology
* ≥ 14% ● Overall shape of the sperm
43
If low semen volume suspect:
*Postejaculatory urinalysis *Retrograde ejaculation *Transrectal U/S *Can show obstruction
44
Specialized semen tests
*Sperm viability *Sperm culture *Sperm biochemistry and fxn *IgA sperm antibodies interfere with sperm-oocyte interaction *IgG sperm antibodies - impaired mobility *DNA fragmentation
45
Treatment for Male Factor
* Hyperprolactinemia *Dopamine agonists (cabergoline, bromocriptine) * Protocol for retrograde ejaculation * Erectile dysfunction medications if indicated * Surgical correction if indicated *Blockage of vas deferen
46
Seminal fluid abnormalities treatment
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
Testicular sperm extraction (TESE)
*After vasectomy *Can reverse vasectomy but not always successful
48
Depending on results of fertility testing different treatment options are available:
● 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
Ovulation Induction
* 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
Clomid (clomiphene)
* 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
Femara (letrozole) - **OFF LABEL USE**
* 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
Gonadatropins (FSH, LH containing mediations)
*Follistim, Gonal F, Menopur *These medications work by giving exogenous FSH and LH to stimulate the ovaries
53
hCG (Ovidrel)
*“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
Intrauterine Insemination
* 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
A good sperm count for IUI is ______
>10 million motile sperm
56
In Vitro Fertilization (IVF)
* 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
The eggs for IVF are retrieved through _____
a VOR (vaginal oocyte retrieval)
58
What is the InvoCell?
Oocytes and sperm are combined in a small device, which is then placed near the cervix for incubation
59
ICSI (Intracytoplasmic sperm injection)
The most common technique used to help with fertilization ○The best looking sperm is selected, immobilized, and injected into the oocyte for fertilization
60
At this time the embryo needs to be transferred into the uterus or frozen, it can no longer grow outside of the body
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
Preimplantation Genetic Testing
*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
FROZEN EMBRYO TRANSFER
* 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
Donor egg:
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
Donor sperm:
Utilizing sperm from a sperm donor with patient’s egg/donor egg and the patient carrying the pregnancy ■Sperm banks ■GCS + CMV status
65
Donor embryo:
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
Gestational carriers can be used for various reasons
■Health issues for the intended parent that make pregnancy dangerous ■Absence of the uterus ■Same sex male couples ■Age of the intended parent
67
What is Co-IVF?
Fertilizing partner’s eggs with donor sperm with other partner carrying pregnancy
68
Same sex female couples IVF options
*Timed donor insemination ■Known donor vs anonymous * Co-IVF ■Fertilizing partner’s eggs with donor sperm with other partner carrying pregnancy
69
Same sex male couples IVF options
* Donor egg with own sperm using gestational carrier ■Known donor vs anonymous
70
Oocyte or sperm cryopreservation
*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

Womens Health Exam 3 (6 decks)

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