Infertility

Question 1

What is the normal conception rate?

Answer 1

monthly 25%

Question 2

What is primary vs. secondary infertility?

Answer 2

primary: inability of couple to conceive after 1 year of sex w no contraception (or 6 mos if >35)
secondary: female has conceived before (even if miscarriage/termination)

Question 3

What is the overall chance of infertility?

Answer 3

15%

Question 4

How can antral follicles be used to work up infertility?

Answer 4

normal around 5/ovary = prelim to an egg

Question 5

What is the most common cause of ovarian dysfunction?

Answer 5

PCOS

Question 6

What are the causes of anovulation?

Answer 6

PCOS, hypo hypo, premature ovarian failure

Question 7

How can mid-luteal progesterone help work up infertility?

Answer 7

> 3 ng/ml means ovulation

Question 8

What is ovarian reserve testing and when is it used?

Answer 8

if female >35: day 3 FSH and estradiol (high is bad), AMH and inhibin B (should be measurable - low is bad), antral follicle counts

Question 9

What factors can indicate tubal dysfunction?

Answer 9

hx of pelvic inf or pain (dysmenorrhea), prior surgery, family hx of endometriosis

Question 10

How can tubal factors be tested?

Answer 10

HSG

laparoscopy in operating room = gold standard

Question 11

What factors can indicate uterine dysfunction?

Answer 11

hx of D&C, recurrent miscarriage, IUD, prior pregnancy outcome

Question 12

What tests can be used to work up uterine dysfunction?

Answer 12

HSG, ultrasound, hysterosonogram, endometrial biopsy to diagnose luteal phase defect

Question 13

What factors can suggest cervical obstacles in infertility?

Answer 13

prior abnormal pap or cervical inf, mid cycle mucus quality

Question 14

What testing can be done to work up cervical obstacles?

Answer 14

pap, post coital test - mucus quality, cultures for gonorrhea and chlamydia

Question 15

In addition to regular menstrual cycles, what other tests can be done to work up ovarian fxn?

Answer 15

TSH, prolactin*, testosterone and DHEA-S if signs of elevated androgens
fasting glucose and insulin levels

Question 16

What are normal values for male sperm:
volume
count
motility
morphology
WBCs?

Answer 16

2-4 ml
>20 million sperm/ml
50-60% motile
WHO normal >50%, strict normal = 6-14%
<1 million wbc/ml

Question 17

What other tests can be done to work up male infertility?

Answer 17

endocrine (FSH, LH, testosterone, prolactin) - look for azoospermia, moderate oligospermia
genetic eval w karyotype - azoospermia not due to blockage, severe oligospermia - Y chromosome microdeletions?

Question 18

When is the best time for:
semen analysis
imaging
ovulation predictor kit
biopsy
lab work?

Answer 18

after 2-3 days abstinence
cycle day 6-10
shortest menstrual cycle and subtract 18
10-12 days after ovulation
cycle day 3

Question 19

What are the treatment options for ovulation induction in PCOS?

Answer 19

oral clomiphene citrate - blocks estrogen feedback at hypothalamus, low multiple gestation, inexpensive
injectable FSH - greater response, multiple gestations, risk of hyperstimulation, expensive

Question 20

What are the treatment options for hypo hypo?

Answer 20

clomiphene citrate ineffective due to axis problem

gonadotropins best option

Question 21

What is the best treatment for ovarian failure?

Answer 21

donor egg/embryo

Question 22

What is the best treatment for tubal/pelvic problems?

Answer 22

usually surgery, IVF

Question 23

What are the treatment options for cervical problems?

Answer 23

treat abnormal pap or positive culture, consider IUI = intra-uterine insemination

Question 24

What are the treatment options for male infertility?

Answer 24

hormonal treatment, IUI for mild (>5 mil total motile), IVF/ICSI for severe oligospermia (5 mil), donor sperm

Question 25

What pts will be unable to conceive w/o therapy?

Answer 25

complete tubal occlusion, premature ovarian failure, hypo hypo, azospermia

Question 26

What pts will conceive eventually even with no therapy?

Answer 26

mild endometriosis, oligospermia, unexplained