Infertility Flashcards
Tests for ovarian reserve and N values (7)
D3 FSH (N: <10IU/L) if >10 IU/L meaning poor responder
Estradiol (N: <50 pg/ml), must be taken with FSH, if >60-80 tapos N FSH = poor responder
Clomiphene Citrate Test
AMH (N: >1.2 ng/ml, if DOR bologna: 0.5-1.1; if Poseidon, <1.2, speroff 0.2-0.7)
AFC (bologna <5-7, poseidon <5 speroff <3-4)
ovarian volume (DOR: <3ml)
inhibin (DOR: <40-45pg/ml)
Clomiphene Citrate Test
Administer 100mg CC on D5-9 x 5 days
D3 and D10 FSH
if 10-22 IU/L = DOR
When to test females for ovarian reserve
35 and above
previous ovarian sx
smoking
previously poor responder
fam hx early menopause
unexplained infertility
substance abuse MOA infertility
marijuana - inhibits GnRH and messes with ovulatory function
cocaine - dec spermatogenesis in males and inc tubal disease women
alcohol - decreased semen parameters and impotence
caffeine - limit to 200mg or 1 12oz coffee or else delay time to conception, miscarriage
smoking MOA infertility
accelerated follicular depletion
menstrual abnormalities
gamete mutagenesis
cycle fecundity
20-30%
cycle fecundability
20%
time to conception in married couples who are fertile
3mo 57%
6mo 72%
1y 85%
2y 93%
causes of infertility
ovulatory 20-40
male 30-40
tubal 30-40
largest # spontaneous pregnancy
within 3 years
chances of winning in life
pregnancy without treatment declines:
by about 5% for each additional year of female partner age
by 15–25% for
each added year of infertility
tests for ovulation
BBT +0.4-0.8F from basal 97-98deg – fertile period 1 week before BBT rise
serum progesterone - <3ng/ml anovulatory, taken 1 week before menses
LH kit must do 2-3 days before expected ovulation, at 4-6pm (ovulation is 14-26 hours after surge and almost all within 48hrs)
EM biopsy - EM date +/- 2
TV-UTZ direct observation of ovary
MOA infertility myoma
1) inc myometrial contractions
2) distortion of endometrial cavity, interfering with sperm transport
3) chronic endometritis, dec endometrial receptivity
4) displacement of cervix - poor sperm exposure
5) tubal blockage if isthmic
6) distortion of adnexal anatomy interfering with ovum capture
The most important prognostic factor for achie ving a live birth afte r microsurgical sterilization reversal is
age
unexplained infertility
10% before age 35
80% at age 40
untreated unexplained infertility fecundability
2-4%
unexplained infertility fecundability with CC + IUI
5-10%
unexplained infertility fecundability with Gonadotropins + IUI
7-10%
unexplained infertility fecundability with IVF
25-45%
Feedback mechanism of FSH in males
LH: testosterone, FSH: ___
inhibin B (produced by sertoli cells)
ADAM
dec libido
DM
metab syndrome
gynecomastia
testicular atrophy
dec muscle mass
inc visceral adipose tissue
sleep disturbances
depressed mood
lethargy
erectile dyfunction
irritability
osteoporosis
increased paternal age
inc numerical and structural chromosomal abnormalities
inc dna fragmentation
inc frequency of point mutations
inc birth defects
inc congenital diseases
inc autosomal dominant mutations
inc chuldren with schizophrenia
inc xlinked disease (hemophilia)
inc autistic children
semen parameters that decrease in aging
volume, motility, morphology
free testosterone index (FTI)
T/SHBG = bioavailable T
hypo T value needs treatment
<200ng/dl
<300ng/dl repeat pero hypo na din
might benefit from tx T level
200-400ng/dl
algorithm if u have low T
repeat T
check LH
if low LH, check prolactin and do MRI
check E2, LH, FSH, T prolactin
contraindications to androgen therapy
prostate/breast CA
prostate nodule
hct >50% erythrocytosis
OSA untreated
severe lower urinary tract symtpoms (IPSS>19)
PSA >3 ng/ml without uro eval
class III or IV HF
T goals therapy
300-400ng/dl
check q3 months
monitoring T tx
q3 months
PSA
serum T
prostate exam
CBC
weight gain/edema
dexa (1-2 yrs after tx starts)
T options for ADAM
parenteral ester IM 75mg/week 150mg q2 weeks
scrotal patch 40cm2 OD
skin patch 5mg OD
testosterone gel 5g/day
side effects of T therapy
edema
prostate disease
fluid retention
gynecomastia
RBC mass/ erythrocytosis
worsening OSA
CVD
hypo-hypo
kallman
single gene deletions
tumors
infiltrative disease
hyperPRL
drugs
illness/injury
chronic illness/malnutrition
infection (meningitis)
obesity
MOA mumps orchitis
destruction of germinal epithelium
immune dysfunction
ischemia
causes of male infertility
hypothalamic-pituitary disorders (1-2%)
primary gonadal disorders (30-40%)
disorders of sperm transport (10-20%)
idiopathic (40-50%)
hyper-hypo
kleinfelter 47xxy
y chromosome deletions
single-gene mutations and polymorphisms
cryptochordism
varicocele
orchitis
chemo drugs
radiation
environmental gonadotoxins
chronic illness
Disorders of sperm transport (7)
epididymal obstruction
vasectomy
CABVD
young syndrome
ejaculatory dyfunction (spinal cord or autonomic)
STD
karatgener’s disease
moa varicocele
delayed removal of local toxins, hypoxia and stasis
more common L>R
abstinence for semen analysis
2-3 days
WHO 2021
1.4ml
39M total sperm count
16M concentration
42% total motility
30% progressive motility
4% normal forms
odds of male infertility
1 -2-3x
2 - 5-7x
3 - 16x
seminal vesicles
alkalaine and with fructose
so if CBAVD = acidic and low volume
acidic = prostate
semen of hypogonadal men
whether 1 or 2 have acidic and onti secretions because no testosterone = no secretions by seminal vesicles
causes of oligo
varicocele
hypogonadism
y chromosome microdeletions (azfa, azfb)
severe oligospermia
<5M
oligo = <20M
forward progression grade of sperm (0-4)
3-4 rapid
2 slow
0-1 nonprogressive
total progressive motility
% of sperm who have purposeful forward motion (2-4)
sperm vitality test
differentiate dead from nonmotile sperm
hypoosmotic sperm swelling test = if mag swell buhay
quality of spermtogenesis is reflected in
sperm morphology
strict criteria of morphology success rate
highest when morphology 14% and above
worst when morphology <4%
true leukocytospermia
> 1M leukocytes/ml
treatment of aromatase inhibitors in males with severe oligo, low T, N gonadotropins
calculate T ng/dl : estradio pg/ml
if <10 = needs AI
MI: goal T if hypo-hypo
400-900ng/dl
check q 1-2 months x 3-4 months
MI: hypo-hypo tx
pre-pubertal na walang pake sa spermatogenesis: give T or HCG alone to induce secondary sex characteristics
if post puberty/adult: give 2500-5000IU HCG
if not working: give HCG + 75-150 IU HMG/FSH
MOA infertility endomet according to CPG (6)
abnormal folliculogenesis
elevated oxidative stress
altered immune action
altered hormonal milieu in follicular and peritoneal fluid
reduced EM receptivitiy
all these lead to:
poor oocyte quality
impaired fertilization and implantation
MOA infertility adeno according to CPG (4)
aberrant uterine contractility, hindering immediate and continuous sperm transport &
embryonic implantation
dec endometrial activity
inc expression of endometrial cytokines and growth factirs
increased expression of CYP450+ aromatase –> local conversion of androgen to estrogen
MOA infertility polyp from CPG (5)
mechanical interference with sperm transport
anatomical interference with implantation
inc production of inhibitor factors (glycodelin)
reduced secretion of implantation factors (IGFBP-1, TNF-a, osteopontin)
unresponsiveness to cyclical hormonal changes
septum outcomes in pregnancy
malpresentation
IUGR
abruptio
perinatal mortality
MOA alcoholism in MI
inc intake > dec FSH and LH > inc testicular damage > dec testosterone/sex hormones > dec secondary sexual characteristics + erectile dysfunction + infertility
lower pregnancy rate and implantation rate seen with women who have
hydrosalpinges
when to do endocrine evaluation in male (3)
oligo <10M/ml
sexual dysfunction
clinical findings of endocrinopathy
what to do if severe oligo <5M/ml
1) karyotyping
2) screen for y chromosome microdeletions
3) check estrogen (elevated), T (decreased), and gonadotropins (N) = may benefit from aromatase inhibitors
