Infertility Flashcards
A 36 yo G1 P0010 LMP 3 weeks ago states she and her husband have been trying to conceive for two years. She is very upset that they have not yet been successful and asks for your help. She states, “I have really good insurance that will pay for everything. I’m afraid my marriage will be over if I can’t get pregnant.”
Your patient has normal periods. Her labs are within normal limits, as is her husband’s semen analysis, but the hysterosalpingogram reveals bilateral tubal occlusion.
She accepts a referral to a reproductive endocrinologist for consultation regarding in vitro fertilization, and thanks you for your help, stating, “I feel like I have some hope now.”
infertility
-85% of healthy heterosexual couples conceive in one year
-Of infertile couples seeking treatment, 85% will conceive
-Definitions of infertility:
-In women <35: Inability to conceive after attempting conception for at least a year
-In women >35: shortened to 6 months
-In women >40: obtain immediate consultation
-Primary infertility: patient has never conceived
-Secondary infertility: patient conceived before but now has not been able to do so
etiology
-In affected couples, the cause is due to
-Female factors: 33%
-About half are due to anovulation
-The other half are due to female reproductive tract structural problems (tubal patency, etc.)
-Male factors: 33%
-Both partners: 33%
etiology of infertility: females
-Anovulation
-MC due to PCOS
-May also be due to thyroid disease or hyperprolactinemia
-Tubal obstruction-
-Adhesions from infections, endometriosis, prior surgery
-Uterine etiologies-
-Endometrial polyps, leiomyomata uteri, Asherman’s syndrome, or Müllerian tract anomalies
-Toxic exposure
-Severe weight gain or loss
-AMA
etiology of infertility: male
-Disorders of the hypothalamus, pituitary, adrenals, or testes
-May be congenital - Abnormal karyotype
-May be acquired- Effect of mumps infection
-Disorders of the post-testicular tract
-Toxic exposure
-Weight gain or loss
-Advanced age
disparities to care for infertility
-females factors are usually investigated initially, with delayed investigation of male factors
-pts who are LGBT or single are more likely to be denied infertility care
fecundability
-the ability to conceive
-in AFAB pts -> fecundability generally begins to decline by 32yo with a steeper rate of decline by 37yo
HPI
-how long has infertility been suspected
-have there been previous studies
-menstrual hx
-obstetrical hx
-prior methods of contraception, if any
-sexual dysfunction
-past abdominopelvic surgery
-frequency of intercourse
-use of lubricants, emollients, etc.
-toxic habits, including alcohol, marijuana, tobacco
-environmental or occupational exposure to toxins
-does male partner have any children
-have any other partners of male partner conceived with a diff partner
-any hx of sterilization procedures in either partner
-any hx of inguinal herniorrhaphy -> potential accidental ligation of spermatic artery
female history
-LMP
-Past medical and surgical history -> Thyroid disease, acne, hirsutism, abdominal surgery
-Gynecologic history -> Ovarian cysts, dyspareunia, endometriosis, leiomyomata uteri, PID, STIs
-Complications of pregnancy and delivery, if any
-History of cervical disease
-Medications
-Allergies
-Toxic habits
-Family history of birth defects or early menopause
-Review of systems
-History of cervical cancer screening
physical exam of female partner
-Weight, vital signs
-Thyroid exam
-Tanner stage
-Breasts
-Evidence of obesity, hirsutism or virilization
-Abnormalities found on pelvic exam: lower genital tract lesions or anomalies, or tenderness, enlargement or masses of uterus or adnexa
ancillary testing of female partner
-Ovulation is generally documented by regular menstrual cycles
-FSH
-TSH
-May consider:
-Anti-Müllerian hormone
-Ovarian volume (via transvaginal u/s)
-Antral follicle count (via transvaginal u/s)
evidence of diminished ovarian reserve
-low anti-mullerian hormone (<1ng/mL)
-antral follicle count (<5-7)
-follicle-stimulating hormone (FSH) >10 IU/L
male history
-Sexual dysfunction- Erectile dysfunction, ejaculatory dysfunction
-History of STIs
-Prior fertility
-Childhood illnesses
-Past medical and surgical history
-Medications, including illicit prescriptions, e.g., anabolic steroids, testosterone
-Allergies
physical exam of male partner
-Careful evaluation of secondary sex characteristics: penis, scrotum, pubic and axillary hair, facial and body hair, etc.
-Penis- Hypospadias
-Scrotum:
-Hydrocele or varicocele
-Testicular size
-Cryptorchidism
-Absence of vasa deferentia
-Prostate - Nontender, normal size
evaluation of male fertility
-If there are no abnormalities identified on history and physical exam, proceed to semen analysis
-May be collected:
-via masturbation (preferred)
-via intercourse using a condom
-Cheap
-Accurate
-Noninvasive
semen analysis
-Volume
-Total sperm number
-Sperm concentration
-Sperm agglutination
-Motility
-Morphology
-pH
anovulation
-Etiologies:
-PCOS
-Hyperprolactinemia or pituitary adenoma
-Menopause
-Premature ovarian insufficiency
-Testing:
-Serum progesterone on day 21, though of uncertain sensitivity
female structural anomalies etiologies
-Adhesions:
-Pelvic inflammatory disease
-Endometriotic implants
-Postoperative adhesions
-Leiomyomata uteri
-Müllerian tract anomalies:
-Bicornuate uterus
-Uterus didelphys
-double vagina
-Vaginal agenesis
-Asherman’s syndrome
ancillary testing of female partner if initial labs are within normal limits
-To rule out tubal obstruction or structural abnormalities:
-Hysterosalpingography (tubal obstruction, Asherman’s syndrome, submucous myomas, Müllerian tract anomalies)
-Transvaginal sonography (endometriomas, leiomyomata uteri, polycystic ovarian syndrome)
-Sonohysterography (endometrial polyps, Asherman’s syndrome, submucous myomas)
-Hysteroscopy (identification and management of endometrial polyps, Asherman’s syndrome, and submucous myomas)
-Laparoscopy: the gold standard (identification and management of endometriosis, adhesions)
female structural anomalies: studies
-Hysterosalpingography:
-Catheter inserted in cervix
-Radio-opaque dye injected
-Patency: spillage of dye from distal tubes should be seen
-Potential problems:
-Painful
-Expensive
secondary structural anomaly: asherman’s syndrome (uterine synechiae)
secondary structural anomaly: submucous myoma
hirsutism vs virilization
-hirsutism- hairy, can be genetic
-virilization- will have hirsutism but also has deeper voice, enlarged cliterous
management of infertility
-FOLIC ACID- All pts capable of becoming pregnant and who are SA with cis men and who want to become pregnant should take folic acid 400 mcg PO daily
-Lifestyle:
-healthy wt
-healthy diet
-reduce stress
-exercise
-avoid smoking, alc, drugs (weed too)
-sex every 2-3 days
ovulatory dysfunction
-Used for pts with:
-PCOS
-Diminished ovarian reserve
-At times, other endocrine disorders (pituitary, thyroid, etc.)
-Clomiphene citrate 50 mg PO daily x 5 days beginning on cycle day 3-5
-Antiestrogen that induces increase in FSH release by blocking estrogen
-increase FSH -> increase follicles
-Perform u/s first to exclude normal follicular and endometrial development
-Obtain neg pregnancy test before beginning clomiphene
-successful in 25-50%
-aromatase inhibitors used for ovulation induction (letrozole)
structural anomalies of the uterus and tubes tx
-Generally require surgery
-Müllerian tract anomalies
-Asherman’s syndrome
-Leiomyomata uteri, especially submucous myomas
-Hydrosalpinx
-Endometriosis
-May also bypass the upper tract by using IVF or use of a surrogate
management of male infertility
-MCC: oligospermia
-Etiology is often unknown
-Management:
-Intrauterine insemination for partners with oligospermia, or with donor sperm
-Artificial insemination
tx options for male infertility: artificial insemination
-Used for:
-Tx of male factor infertility
-Management of female pts without a male partner
-May place sperm:
-At cervix
-In uterine cavity (intrauterine insemination [IUI]):
-Ideally performed after spontaneous LH surge or after administration of 10,000 units of exogenous HCG (mimics LH)
-Success rate of IUI is 8% per cycle
-85% of successful IUIs occurs within first 4 artificial IUIs
In vitro fertilization
-First successful IVF occurred in 1978
-Select an oocyte prior to ovulation after:
-Ovarian stimulation
-Aspiration of follicle- 36 hrs prior to administration of HCG (to induce ovulation)
-Classification of oocyte by embryologist
-Preparation of semen after analysis and donation
-Insemination of oocyte in laboratory
-Culture of embryo
-Transfer of embryo into endometrial cavity, usually on cycle day 5
intracytoplasmic sperm injection (ICSI)
Sperm are extracted from the testicle or epididymis directly and are then injected into the oocyte through the zona pellucida and cell membrane
gamete or zygote intrafallopian transfer (GIFT or ZIFT)
-GIFT- used for unexplained infertility
-oocytes and sperm are placed in a catheter through the fimbria via laparoscopy
-ZIFT- a zygote (not gametes) is transferred into the fallopian tube during laparoscopy
ovarian hyperstimulation syndrome
-Complication of management of anovulation
-Self limited syndrome; will resolve
-Characterized by:
-Ovarian enlargement
-Ascites
-Weight gain
-Abdominal pain
-Severe hyperstimulation syndrome may also include:
-Hydrothorax
-Dyspnea
-Oliguria
-Hemoconcentration
-Renal insufficiency
-Tx of severe ds:
-Hospitalize
-Normal saline IV
-Albumin 25% IV at 50 ml/hr x 4 hrs until oliguria improves
-Consider paracentesis for discomfort from ascites
-Heparin prophylaxis to prevent DVT
which of the following best identifies appropriate management of 38yo pt with secondary infertility with severe ovarian hyperstimulation syndrome
-hemodialysis
-admin of albumin 25%!!!
-D5 1/2 normal saline IV
-furosemide 40mg PO Q6h
